Home › New Patient FormNew Patient Form Patient Name * Email * Phone Number Current Address * Marital Status * What is your height? * What is your current weight? * Select Reason for Visit * Arm LiftBreast AugmentationBreast LiftBreast ReductionBreast RevisionImplant RemovalBrow LiftBuccal Fat RemovalChemical PeelEyelid SurgeryEarlobe ReductionFace/Neck LiftFacial ImplantsForehead ReductionHair RestorationInjectables-neurotoxins/fillersLabiaplastyLip LiftLiposuctionLower Body LiftMicroneedlingMommy MakeoverRhinoplastyThigh LiftTummy TuckOther History (fill out why you are here, what brought you to want this procedure, etc.) * Primary Care Physician Physician Name * Phone Number * How Did You Hear About Our Office? * WebsiteFacebookInstagramSaw Your SignOther/Personal ReferralEmergency Contact Emergency Contact Name * Relationship * Work Number * Cell Phone * Email * Preferred Pharmacy Information Pharmacy Name * Address * Phone * Medical History No significant past medical history Medical History (Enter details below) ArthritisAsthma or Lung DiseaseCancerDiabetesHeart ConditionsHigh CholesterolHypertensionHypotensionKidney DiseaseLumbagoLumbosacral root lesionsLupusPeripheral neuropathySeizures or EpilepsyScoliosisSpinal stenosisStrokeThyroid DiseaseOther Enter details of medical history Other Medical History Not Listed Above Past Surgical History Patient has no Previous Surgeries Medical History (Enter details below) Abdominal SurgeryAppendectomyArm LiftBladder Repair/SuspensionBody LiftBreast AugmentationBotoxBreast LiftBreast ReductionBrow LiftCardiac Surgery including StentsCesarean SectionCholecystectomyEyelid SurgeryFace LiftFacial FillersHernia RepairHysterectomyJoint ReplacementLiposuctionNeck LiftOophorectomyOrgan TransplantSpinal SurgerySplenectomyThigh LiftTonsillectomyTummy TuckOther Please include the year you completed your past surgery. Please list the procedure(s) next to the year if multiple surgeries have been selected. Allergies I Have No Known Allergies Allergies PenicillinSulfaCephalosporinsQuinolonesIodineLatexDairyOther What reactions did you have, if any? Current Medications Classes of Medications Blood ThinnersChemotherapyDiabetes MedicationsPsychiatric MedicationsRheumatoid MedicationStatinsSteroidsNo Current MedicationsOtherFamily History No significant family history Family History DeceasedDiabetesHypertensionCancerHypotensionSkin DisordersEnvironmental AllergiesAsthmaHeart DiseaseGI ProblemsEmphysemaLipid DisordersAuto-Immune DiseaseCardiovascular DiseaseBronchitisArthritisHeadachesRheumatoid ArthritisStrokeGERDLung DiseaseObesityBlood DisorderPkdSocial History: Smoking Have You Ever Been A Smoker? * YesNo Are You Currently Smoking? * YesNo If You Answered No, When Did You Quit? If You Answered Yes, How Much Do You Smoke? 1-4 cigarettes per dayMore than 5 cigarettes per daySocial Smoking Have you been offered Tobacco Cessation Counseling? YesNo Do you vape? YesNo Do You Use Any Form of Nicotine or Nicotine Replacement Therapy? If So, What Products? GumInhalersLozengesNasal SpraySkin PatchOtherSocial History: Alcohol, Drugs, Occupation, Hobbies Do you drink alcohol? * YesNo How Much Alcohol Do You Drink? Socially, On Occasion1-2 Drinks Per Day3-5 Drinks Per DayMore Than 5 Drinks Per Day Do You Use Recreational Drugs? * YesNo Drug Usage Details CocaineHeroinCannabisEcstasyLSDBenzodiazepinesPCPAdderallBarbituratesAmphetaminesOpiatesKetamineMescalineASDF What Are Your Hobbies / Athletic Activities? * Occupation (Answering This Question Helps Guide The Surgical Recovery Discussion) * Other: (Must Show Valid ID) Please SelectFirefighterFirst ResponderMilitaryTeacherNursePhysician Other: (Must Show Valid ID) Please SelectFirefighterFirst ResponderMilitaryTeacherNursePhysician Signature* By completing this form, you're consenting to email and SMS marketing and can unsubscribe at any timeI agree to receive text messages from New Image Plastic Surgery, including appointment reminders, scheduling confirmations, post-procedure follow-ups, and occasional promotional offers. Message frequency varies. Message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance. See our Privacy Policy for details on our SMS messaging program. We do not share or sell your mobile information to third parties. Protected by Recaptcha. Privacy & Terms
