Patient Registration Form

  • It is very important to completely and accurately fill in all the fields before submitting.
  • Make sure you indicate dates and areas of prior liposuction or non-surgical fat reduction treatment.
  • Please use your TAB key to move to the next field. Thank you.

    • Personal Details

    Patient Name*:
    Last name

    First name
    Mid name
    Home Address*:
    City:
    		Zip:
    State:
    		Country:
    Cell Phone#:* Alternate#:*  
    Email address*:
    Birthday*:
    		Gender:    Male Female
    Ethnicity:
    Job title / Description:
    Employer:
    Phone#:
    Emergency contact person:
    Relationship:
    Phone#:
    Reason for visit / Consultation:

    Medical History

    Please list all medical conditions you are being treated for:
    Please list all surgeries you have had in the past:
    Please list all medications and dosages that you take:
    Please list all vitamins or supplements that you take:
    Are you on birth control?   Yes No
    Please list:
    Allergic to any medications?   Yes No
    Please list:
    Do you smoke?   Yes No
    How much?
    Height:
    Current Weight:
    Your goal weight:
    The maximum you have ever weighed:
    Has your weight been stable for 6 months?

    Women's Health:
    1. Number of pregnancies:
    2. Number of miscarriages:
    3. Number of living children:
    4. Ages of living children:
    5. Breast measurement and cup size:
    6.Desired breast cup size:
    7. Did you breastfeed? Yes No
    8. Do you have a history of breast cancer? Yes No
    9. Do you perform self breast exams? Yes No
    10. Date of last mammogram:
    11. Do you have any breast masses or abnormalities? Yes No
    12. Breast pain? Yes No
    13. Family history of breast cancer? Yes No
    If so, who?

    Review of systems: Do you have, or have you ever had, any of the following:

    Head:
    Headaches Yes No
    Migraines Yes No
    Epilepsy Yes No
    Anxiety Yes No
    Depression Yes No
    Mental health disease Yes No
    Eyes:
    Contact lenses Yes No
    Dry eyes Yes No
    Excessive tearing Yes No
    Retinal dettachement Yes No
    Cataracts Yes No
    Glaucoma Yes No
    Visual field obstruction Yes No
    Nose:
    Difficulty breathing Yes No
    Frequent bloody nose Yes No
    Sinus infections Yes No
    Blood:
    Easy bruising Yes No
    Blood clots Yes No
    Body:
    Unintentional weight loss Yes No
    Cancer/tumor Yes No
    History of radiation Yes No
    History of chemotherapy Yes No
    Arthritis Yes No
    Muscle aches Yes No
    Back pain Yes No
    Fibromyalgia Yes No
    Excessive scarring or keloids Yes No
    Lungs:
    Shortness of breath Yes No
    Asthma Yes No
    COPD Yes No
    Emphysema Yes No
    Bronchitis Yes No
    Tuberculosis Yes No
    Heart:
    Heart disease Yes No
    High blood pressure Yes No
    High cholesterol Yes No
    Chest pain Yes No
    Murmur Yes No
    Palpitations Yes No
    Arrhythmia or Irregular heart
    rhythm    		 Yes No
    Ankle swelling Yes No
    Sleep apnea Yes No
    Organs:
    Kidney disease Yes No
    Liver disease Yes No
    Infections:
    Recent cough or cold Yes No
    Fever Yes No
    Night sweats Yes No
    Hepatitis B/C Yes No
    HIV Yes No
    AIDS Yes No
    Other immune deficiency Yes No
    Other:
    Any other info:

    How did you find us? (check all that apply):

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    Referred by:
    Other:


    *Patient signature:
    		   Date: