Patient Information

Contact & demographics

First Name *

Last Name *

Date of birth *

Pronouns

How you'd like our team to refer to you

Sex

Male

Female

Email *

Cell Phone *

Address

Street Address

City

State

Country

Enter your country

Postal Code

Primary Medical Doctor

Reason for visit

How did you hear about us?

How did you hear about us? (copy)

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Medical History

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?

Do you have a pacemaker / AICD device?

Yes

No

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

ALLERGIES to any medications

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

Diet Pills / GLP-1?

Social History

Do you smoke cigarettes?

Yes

No

Have you ever smoked?

If yes, how many packs per day?

How many years?

Drug Use

Alcohol Use

None

Social

Daily

Daily Exercise

Never

> 1x per week

4–6x per week

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

Women's Health

If applicable

Are you certain you are NOT pregnant?

Yes

No

Date of last menstrual period

Do you take oral contraceptive pills?

Yes

No

Date of most recent mammogram

Current bra size

Medical Insurance

Only if non-cosmetic / using insurance

Insurance Company

Member / ID#

Insurance Group#

Policyholder (if not patient)

Policy Holder's DOB

If under Age 18

Parent / guardian information

Parent / Guardian Name

Phone

ACKNOWLEDGEMENT & SIGNATURE

I certify the information above is accurate and complete to the best of my knowledge.

Signature

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