Top Plastic Surgeon
San Antonio, TX

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Facial Patient History and Physical

Date: *

Patient Name: *

Email *

Date of Birth: *

Occupation: *

Address: *

Cell Phone: *

Home Phone: *

Emergency Contact Name and Phone: *

Medical History

Do you have any of the following medical conditions (please check those that apply): *

Cardiac Problems (e.g. pacemaker or defibrillator)High Blood PressureBleeding Disorders (bruise easily)Keloids/ScarringDaily use of anticoagulants or aspirinImpaired HealingDiseases stimulated by light (e.g. Epilepsy)CancerDiseases stimulated by heat (Herpes Simplex)Frequent cold soresSkin disorders or skin lesionsDiabetesHormone Imbalance (e.g. PCO)HepatitisMelasma/PIHThyroid DisorderAutoimmune disorder (e.g. Lupus, HIV/AIDS)None of the above

Please explain if you checked any of the above:

Medications

Have you ever used Accutane for acne treatments? * YesNo

Dates Used:

Please list all prescription medications you are currently taking: *

Please list all OTC medications and supplements you are currently taking: *

Have you ever had an allergic reaction to the following (please check those that apply): *

LatexLidocaineAnesthesiaTopical AnestheticOtherNone of the above

Please explain:

Female Patients:

Are you pregnant?Are you breastfeeding?

Surgical History (including cosmetic) – Please list all surgeries and the year they were performed: *

Cosmetic Treatment History – Please list all treatments and the year that they were performed: *

Are you under the care of a physician or dermatologist at this time? * YesNo

Do you smoke? * YesNo

Do you drink alcohol? * YesNo

Skin Type

Ethnicity: Please check all that apply (even if you are a combination of the below) *

WhiteAsianMediterraneanBlackHispanicMiddle Eastern

Which of the following describes best your skin reaction when you are in the sun? * Always burn, never tan (Type I)Burn easily, tan minimally (Type II)Burn and tan moderately (Type III)Rarely burn, tan easily (Type IV)Rarely burn, tan profusely (Type V)Never burn, tan profusely (Type VI)

Are you tan now? * YesNo

From sunFrom tanning bedFrom tanning lotion

Will you be exposed to the sun in the near future? * YesNo

Do you use sunscreen? * NeverSometimesAlways

What SPF do you use? *

How often do you apply your sunscreen during the day? *

Do you have any problems with hyperpigmentation (dark skin coloration) or hypopigmentation (light skin discoloration)? * YesNo

Location:

What skin care products do you use? *

Have you had any injections or fillers in the area to be treated? If so, please specify: *

Do you have any tattoos (including permanent makeup)? * YesNo

If yes, please specify the location:

Do you have any moles, birthmarks, or any other dark lesions? * YesNo

If yes, please specify the location:

When were these lesions last checked by a physician?

Patient Signature *

Date *

Disclaimer: This clinical form is presented for information purposes only. This document cannot and should not be used as a basis of diagnosis or choice of treatment, and is not intended to replace professional medical care or attention by a qualified practitioner.

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New Image Plastic Surgery is my go-to for all things aesthetic! Whether it’s Botox, hair removal, or RF micro needling, Dr. Brostrom, Dr. Homas, and the team make every experience fantastic. I always recommend them to anyone on the lookout for exceptional aesthetic or plastic surgery services.

- Happy Patient

Dr. Dallas Homas is a very good surgeon! He is thorough, kind, and extremely knowledgeable. I’d recommend him to anyone. The facility is very nice and very clean two critical aspects that I look out for on my first visits. Of course, his office passes with flying colors! Even the staff is amazing!

- Happy Patient

Dr. Brostrom is an exceptional surgeon. I had abdominoplasty, lipo, and breast augmentation and she and her staff made the experience fun, welcoming, and absolutely worthwhile. I have noticed that my healing is much faster than what I have seen on average.

- Happy Patient

I’ve always been self-conscious about my facial features. I was so nervous to seek a consultation, I was sweating and my heart was pounding. The girl at the front desk was so nice and Dr. Homas was friendly, patient, and kind. He answered all of my questions and made it easy to understand. I felt safe and at ease.

- Happy Patient

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Whether you are looking for a subtle improvement or a big change, our staff will work with you to create a personalized treatment plan fit for your lifestyle! If you would like to get started on your journey to a new and improved you, please fill out the form below, or give us a call at (210) 640-6310

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20255 Stone Oak Pkwy San Antonio, TX 78258

(210) 640-6310

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Top Plastic Surgeon San Antonio, TX

Medical History

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Top Plastic Surgeon
San Antonio, TX