Patient Information

Contact & demographics

First Name *

Last Name *

Email *

Cell Phone *

Date of birth *

Age

Pronouns

How you'd like our team to refer to you

Social Security Number

Address

Street Address

City

State

Country

Enter your country

Postal Code

Reason for visit

Primary Medical Doctor

OB/GYN

Employer

Occupation

Employer Address

Spouse's Name (If applicable)

Referred by

How did you hear about us?

Medical Insurance

Only if non-cosmetic / using insurance

Name of person holding medical insurance (if different from patient)

Primary Insurance Company

Policy Holder's SS#

Policy Holder's DOB

Insurance ID#

Insurance Group#

Secondary Insurance Company (if applicable)

Secondary Insurance ID#

Secondary Insurance Group#

Workers' Compensation Case# (if applicable)

If Comp — contact at workplace (name & phone)

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship

For Patients Under Age 18

Parent / guardian information

Father's Name

Father's Employer

Father's Work Phone

Father's SS#

Mother's Name

Mother's Employer

Mother's Work Phone

Mother's SS#

Medical History

Sex

Male

Female

Race

Height

Weight

Past Medical History — conditions you've been treated for

Past Surgical History — operations, including cosmetic

Are there ANY other conditions we should know about?

Social History

Do you smoke cigarettes?

Yes

No

If yes, how many packs per day?

How many years?

Have you ever smoked?

If you stopped, when?

Alcohol Use

None

Social

Daily

Daily Exercise

Never

> 1x per week

4–6x per week

Drug Use

Tranquilizers

Diet Pills / GLP-1?

Family History

Has any family member had any of the following? (check all that apply)

Heart attack

Cancer

High Blood Pressure

Breast Cancer

Diabetes

Reaction to Anesthesia

Kidney Disease

Depression

Other

Elaborate

Medications & Allergies

All MEDICATIONS and dosage recently or regularly taken (include herbal & vitamins)

ALLERGIES to any medications

NON-MEDICINE allergies (e.g., latex, nickel, seasonal)

Do you have a pacemaker / AICD device?

Yes

No

Women's Health

If applicable

Do you have children?

Yes

No

How many?

How many times pregnant?

Date of last menstrual period

Are you certain you are NOT pregnant?

Yes

No

Do you take oral contraceptive pills?

Yes

No

Date of most recent mammogram

Mammogram results

Breast aug/reduction — current bra size

Breast aug/reduction — desired bra size

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