Microsoft word - cosmetic form.doc

Patient Information
Name:_________________________________________ Would you like to be addressed by your first or last name in
the waiting area? Please circle. FIRST LAST
Address: _______________________________________ Is this the address you would like correspondence and billings sent to? YES NO
City: ____________________ State: ____ Zip: _______ May we leave messages at these following numbers? (appointment reminders, lab & x-ray results, etc.) Home Phone: _______________________________ ____ Work Phone: _______________________________ ____ Cell Phone: _______________________________ ____
Email Address: ______________________________ ____ May we send you information via email? YES NO
Date of Birth: ______________________________ ____ SSN: ________________________________ Marital Status: S M W D MALE FEMALE (Please Circle) Occupation: ________________________________ _________________________________________ Name of Employer: __________________________ _________________________________________ Emergency Contact: __________________________________________________________________ Emergency Contact Phone #: _______________________________ Relation:____________________ REASON FOR TODAY’S VISIT: __________________ _________________________________________ How did you hear about our office? ______________ _________________________________________ If you were referred by a physician, please provide Physician’s Name: _____________________________________ Primary Care Physician: _______________________ _____________ Phone #:____________________ How long have you been thinking of pursuing this procedure? ___________________________________ Have you had any cosmetic surgery before? YES NO If so, when? _____________________________ Which procedures? ___________________________ __________________________________________ Have you consulted any other physicians for this pr pI have completed the imaging/photograph consen t on the backside of this paper. _____________________________________________ ________________________________________________ Health History
Name: _____________________________________ _____________________________________________ Age: _______________________ Height: ________ __________ Weight: ____________________________ Date of Last Physical: _______________________ Date of Last Chest X-ray: _________________________ Date of Last EKG: _________________ Do you smoke or use tobacco? _______ If yes, how much?________ Do you drink alcohol? ______________________ If ye s, how much?_________________________________ Would you like a chaperone present during your exam with Dr. Stroup? YES NO *I f yes, who is your cardiologist? ___________________
Do you have any other illness/medical conditions not m entioned above? ______________________________
Are you allergic to any medications? YES NO If yes
, which ones? ________________________________ ____________________________________________ ___________________________________________
Have you recently taken any medications? YES NO
If yes, which ones? __________________________ ____________________________________________ ___________________________________________
Do you take vitamins or herbals? YES NO If yes,
which ones? _________________________________ _______________________________________________________________________________________ Do you have a history of cold sores, herpes, or similar lesions? YES NO
Are you taking any of these medications?
Blood Thinners
Please list any previous surgeries. ___________ ________________________________________ ________________________________________________ ___________________________________________________ ________________________________________________ ___________________________________________________ Did you experience any postoperative nausea following these surgeries? YES
FEMALES: Are you pregnant? YES NO Number of Pregnancies:_____ Number of Children:_____
When was your last mammogram? ___________ _______________________________________
ra Size: ________ Would like to be: ___________________ Do you do self-exams on a regular basis? Is there a history of breast cancer in your family? Do you have a history of breast problems (ie. cysts, bumps, etc.)? YES NO
I have answered the questions concerning my health to the best of my knowledge.

________________________________________________________________________________________ Patient’s Signature PHOTOGRAPH & IMAGING CONSENT
In the course of the consultation and discussion with Dr. Robert Stroup, I may have been shown, or may be shown or provided certain brochures, or pictures on an electronic computer imaging device. I understand that those pictures and alteration of those pictures seen are solely for the purpose of illustration/discussion and to provide improved communication with the doctor. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics and health. I further understand and acknowledge that because of the obvious significant difference in how living tissues react to surgery, there may be no relationship between the electronic images created, and my actual final surgical result. Use of the computer imaging system offers an opportunity for me to discuss my desires and to allow an improved communication with the doctor. p I hereby do grant permission for the use of any illustrations, photographs or imaging records created in my case for use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity. p I hereby do not grant permission for the use of any illustrations, photographs or imaging records created in my case for use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity. I certify my understanding that there is NO WARRANTY, expressed or suggested, as to my own final appearance after elective surgery by the use of these electronically altered images. _______________________________________________________ Patient

Source: http://advancedconcepts.net/FILES/COSMETIC%20FORMS.pdf