Patient Medical Form

Hypertension

YesNo

Diabetes

YesNo

Heart Disease

YesNo

Skin Cancer

YesNo

Hypertrophic Scarring (Keloid)

YesNo

Aspirin/Fish Oil Use

YesNo

Tobacco Use

YesNo

Accutane Treatment

YesNo

Previous Aesthetic Surgery

YesNo

Please list all medications you are currently taking (perscription, over the counter, or naturopathic):

Please list any know allergies to medications:

Please list all past surgeries:

Please indicate the services that you are interested in. Use the space provided to specify a particular area of concern:

Botox, XEOMIN Injections (Used to treat frown lines & crow’s feet)

Juvederm/Radiesse/Sculptra Injections – indicate area

Laser Resurfacing/Skin Rejuvenation

Face/Neck/Brow Lift

Eyelid Surgery

Nasal Refinement/Nose Surgery

Ultherapy

CoolSculpting

Liposuction – Please indicate area(s)

Breast Augmentation/Breast Lift

Tummy Tuck

Other – please specify