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RSJ Plastic Surgery
Print blank form to fill by hand

Patient Registration Information

*Patient Name:

Last name

Mid name

First name

I prefer to be called:

Birthday:

Age:

Gender: Male Female

Social security#:

Driver’s license#:

*Address:

				City
State		Zip		APT#

*Home phone #:	()- -	Cell #:	()- -
Work phone #:	()- - -

*Email Address:

Where & when are best times to reach you?

How did you hear about us?

Whom may we Thank for referring you?

Other family members seen by us:

Person responsible for account:

Employer Details-

Employer:

Address:

				City
State		Zip		APT#

Occupation:

How long there ?

Spouse Information-

His / Her name:

Employer:

Birthday:

Social security#:

Address:

				City
State		Zip		APT#

Work phone #:

()- - -

Cell phone #:

()- -

Driver’s license:

Emergency Contact Details (Relative or friend not living with you)-

His / Her name:

Relationship:

Work phone #:

()- - -

Home phone #:

()- -

Insurance Information

Primary Insurance Details -

Insurance Co.:

Address:

				City
State		Zip		APT#

Phone:

()- -

Group#:

Insured’s name:

Relationship:

Birthday:

Social security#:

Insured’s employer:

Address:

				City
State		Zip		APT#

Secondary Insurance Details-

Insurance Co.:

Address:

				City
State		Zip		APT#

Phone:

()- -

Group#:

Insured’s name:

Relationship:

Birthday:

Social security#:

Insured’s employer:

Address:

				City
State		Zip		APT#

Medical History

Do you have a personal physician?

Yes No

Physician’s Name:

Telephone #:

()- -

Date of last visit:

Your current physical health is:

Good Fair Poor

Are you currently under the care of a physician?

Yes No

If Yes, Explain:

Is there a history of deep venous thrombosis (D.V.T.)?

Yes No

If Yes, Explain:

Is there a history of pulmonary embolism (P.E.)?

Yes No

If Yes, Explain:

Have you had any metal rods, pins or implants?

Yes No

Are you taking any prescription / Over-the-counter drugs?

Yes No

If Yes, Explain:

Have you ever taken Fosamax, or any other bisphosphonate?

Yes No

For Women-

Are you using a prescribed method of birth control?

Yes No

Are you pregnant?

Yes No

Week #:

Are you nursing?	Yes No
Have you ever had a mammogram?	Yes No

When was your last menstrual cycle?

In your life, how many pregnancies have you had?

How many children do you have?

Please list any serious medical condition(s) that you have ever had:

Please list any other drugs / Materials that you are allergic to:

Please list if you have any other Past Surgical history:

Social History-

Do you smoke?

Yes No

If Yes, How Much:
How Long:

Do you drink alcohol?

Yes No

If Yes, How Much:
How Long:

Do you recreational drugs such as marijuana?

Yes No

If Yes, How Much:
How Long:

Family Medical History-

Is there a family history of breast cancer?

Yes No

If Yes, Who is affected:

Mother Father Sister Brother

Is there a family history of any kind of cancer?

Yes No

If Yes, Who is affected:

Mother Father Sister Brother

Is there a family history of diabetes?

Yes No

If Yes, Who is affected:

Mother Father Sister Brother

Is there a family history of problems with anesthesia?

Yes No

If Yes, Who is affected:

Mother Father Sister Brother


*	The information and preceding answers are true and correct to the best of my knowledge. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.

*Signature:		Date:
(Your digital signature (full name) is as legally binding as a physical signature.)