Bleeding Tendency: No
Diabetes: No
Blood Transfusions: No
Glaucoma: No
Dry Eyes: No
Lung Disease: No
TB: No
Asthma or Wheezing: No
Emphysema: No
Bronchitis:
Irregular Heart Beat: No
Chest Pain: No
Heart Disease: No
High Blood Pressure: No
Pace Maker: No
Heart Attack: No
Stroke: No
Epilepsy: No
Heart Burn: No
Intestinal Ulcurs or Bleeding:
No
Rheumatoid Arthritis: No
Skeroderma: No
Lupus: No
Porphyria: No
Depression: No
Mental Illness: No
Drug or Alcohol Addiction:
No
Hepatitis B: No
Hepatitis C: No
HIV: No
Contact Lenses: No
Loose or Chipped Teeth: No
Dentures: No
Dental Implants: No
Caps: No
None: No
Any Other Serious Illness or Injury: Please
check this box and explain in the field below: No
Height:
Units:
Weight:
Units:
Are you now or have you ever been a
smoker?: No
If you are an ex-smoker, for how long
are you smoke free? (Years):
For how long did you smoke? (Years):
How much are (were) you smoking?
(Cigarettes per day):
How much alcohol do you drink per week?
(Servings):
How much caffeine do you drink per week?
(Servings):
Do you have a history of cold sores?
No
When was your last outbreak of cold
sores?
Do you or your family have a history of
atypical moles, vitiligo, developing keloids, melanoma, or skin cancer?: No
If you or your family have a history of
atypical moles, vitiligo, developing keloids, melanoma, or skin cancer, please
explain:
Is there any possibility you may be pregnant at
this time?: No
Please list all the surgeries that you have had
(include plastic surgery and wisdom teeth removal) with the date you had the
surgery.
Name of Surgery:
Date of Surgery:
Name of Surgery:
Date of Surgery:
Have you or anyone in your family ever had or
have a history of unusual reactions or problems with LOCAL anesthesia (dental
freezing). TOPICAL anesthesia (anesthetic creams or gels) or GERERAL anesthesia
(rashes, muscle weakness, jaundice, breathing problems, or unexpected fevers(s)?
If yes, please explain:
Have you ever seen a cardiologist?
Physician Name:
Date of Last EKG:
I acknowledge that I have disclosed my complete
medical history and the above is a complete and accurate representation of
my medical and psychological status. I,
represent to the physicians and staff that I am
at least 18 (eighteen) years of age or, if not, am accompanied by a legal
guardian. I hereby consent to and authorize a history examination by my doctor
and such assistant or staff as may be assigned by him/her. If appropriate, I
authorize the release of any medical information for the purpose of processing
insurance claims on my behalf. I authorize payments of medical benefits directly
to the doctor for services provided to me. A copy of this authorization shall be
considered as valid as the original. I understand that photography is a
necessary part of planning and evaluating cosmetic procedures. I authorize the
taking of photographs at the direction of my physician or physician delegate and
under such conditions as may be approved by him/her. These photographs wil be
used solely for documentation purposes and will be kept confidential unless
otherwise disclosed. I understand that there is a consultation fee for the
initial visit which is due at the time of my appointment unless other
arrangements have been made in advance.
Signature:
Date:
Relationship (select one):