Texas Plastic Surgery: New Patient Form

Texas Plastic Surgery: New Patient Form

Texas Plastic Surgery: New Patient Form

Texas Plastic Surgery: New Patient Form

Demographics

***Please provide a copy of your Driver's License and Insurance Card(s) to the staff.

Complete this section only if someone other than the patient is financially responsible.

Personal Physician

1 of 3

Medical History
Medical

Do you or have you had:

Prolonged bleeding when cut
Blood clots in legs
High blood pressure
Heart murmur or disorder
Heart Disease or attack
Chest pain or shortness of breath
Fainting or blackout episodes
Hepatitis
Diabetes
Fever blister or cold sores
Surgical

Previous Operation(s) (Childbirth)

Date

Allergies

Are you allergic or have reactions to medications, drugs, or local anesthetic medication?

Medication

Reaction When Last Taken

Current Medications (List all medications including aspirin and birth control)

Do you take or have you taken Accutane?

Frequency Take

Bleeding / Transfusions
Aspirin Intake in the past two weeks?
Prolonged bleeding when cut?
Family history or prolonged bleeding?
Have you had blood transfusions?
Reactions to blood transfusions?
Scarring
Have you formed excessive, unsatisfactory scars, or
keloid formations in the past?
History

Is there a history of the following in your immediate family? If so, please list the family member

Heart Attack
Diabetes
Blood disorders
Breast Cancer
Cancer
Stroke
Personal History
Do you smoke?
If yes, how many packs per day?
Do you drink alcohol

Thank you! We will review the information and get back to you shortly.

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