Patient Admittance Form
Full Name :
Male / Female :
Birthdate :
Email Address :
Address :
City:
State / Province :
Zip COde / Pin Code :
Please include country and city code with phone numbers.
Cell Phone :
Which Cosmetic Surgery procedure you are interested in? :
What specifically are your objectives and concerns? :
Please complete the following.
 
No
Yes
 
Do you have any health problems? If Yes, please describe:
Have you had any major surgery? If Yes, please describe:
Have you had any cosmetic surgery? If Yes, please describe:
Have you any major injuries? If Yes, please describe:
Do you take any medications/nutritional supplements/herbal medications? If Yes, please describe:
Have you ever had any adverse reaction to local or general anesthesia?
Do You take Aspirin/Blood Thinners?
Have you had an allergic reaction to medication? If Yes, what type and what year:
Do you any allergies? If Yes, please describe:
Do you have any bleeding problems? If Yes, please describe:
Do you smoke? If Yes, how much?
Do you take alcohol or other recreation medicines/drugs? If Yes, please describe:
Do you have any children? If Yes, how many, and how old is the youngest?
The following questions concern you and your family. Please tick Yes for yourself and/or state which Family Member has the problem :
 
Self
 
 
 
No
Yes
Family Member
Neurological Disorder?
Diabetes?
Heart Problems?
Breathing / Lung Problems?
Gastrointestinal Problems?
Kidney Problems?
Do you have any skin problems/skin cancer? If Yes, please describe:
Other medical problems, including communicable diseases? If Yes, please describe:
I understand that all the information furnished above is accurate and true.