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(201) 948-5000
Book A Free Consultation
About
Treatment Areas
Chin & Neck
Abs
Back
Bra Fat
Love Handles
Before & After Gallery
Contact Us
Blog
Home
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Forms
Forms
Surgical Evaluation Form
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
What are your areas of concern?
(Required)
Weight
(Required)
Height
(Required)
Have you ever had an aesthetic treatment?
(Required)
Yes
No
Do you have surgical history?
(Required)
Yes
No
If yes, which?
Do you have allergies?
(Required)
Yes
No
If yes, which?
Do you have oncological history (cancer)?
(Required)
Yes
No
Do you have regular bowel movements?
(Required)
Yes
No
Do you practice physical activity?
(Required)
Yes
No
If yes, how often?
Do you use tobacco?
(Required)
Yes
No
If yes, how often (per day, years, etc.)?
Do you drink alcohol?
(Required)
Yes
No
If yes, how often (per day, week, etc.)?
Do you use recreational drugs?
(Required)
Yes
No
If yes, please list all and last date of use.
Do you have regular sleep?
(Required)
Yes
No
How many hours a night?
(Required)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Do you drink water frequently?
(Required)
Yes
No
How many glasses a day?
(Required)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Do you have any health issues? (Diabetes, Hypertension, etc.)
(Required)
Yes
No
If yes, please list and explain.
Please list any medications, supplements, or vitamins you use on a daily basis
(Required)
Do you use blood thinner medication?
(Required)
Yes
No
If yes, which?
Do you drink coffee or tea?
(Required)
Yes
No
Do you have history of keloids?
(Required)
Yes
No
Do you have history of hormonal change or replacement?
(Required)
Yes
No
Do you have history of being vaccinated less than 6 months ago?
(Required)
Yes
No
If yes, which and when?
Are you prone to cold sores?
(Required)
What is your value of blood pressure since the last measurement?
(Required)
Do you have any autoimmune disease or that degrades the immunological system (HIV, Lupus, Rheumatoid Arthritis, Autoimmune Dermatitis, etc.)
(Required)
If yes, which?
How did you hear about us?
(Required)
RESPOND TO THE FOLLOWING ONLY IF YOU ARE FEMALE
Are you pregnant or breastfeeding?
Yes
No
Are you using any method of contraception?
Yes
No
If yes, which?
Date of last menstruation?
MM slash DD slash YYYY
Are you experiencing menopause?
Yes
No
If yes, what is the date of your last menstruation?
MM slash DD slash YYYY
Consent
(Required)
I agree to the privacy policy.
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you
have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare
operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health
Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or
healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous
usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not
be retroactive.
By signing this form, I understand that:
Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those
restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.
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Signature
(Required)
