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Luxe at DFPS

(513) 891-LIFT(5438)

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Patient Sign-In and Health Information

For information on our procedures or to schedule an appointment call us at 513-891-LIFT (5438)

You may also send us an inquiry by filling out theshort form below.

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Date*

MM slash DD slash YYYY

Patient's Name*

Last Name*

Email*

Phone*

Reason for today's visit*

Procedures I would like to discuss with the doctor:

Facial Rejuvenation

Necklift

Facelift

Eyelid Correction

Forehead/Brow Lift

Fat Transfer

Nasal Surgery

Cosmetic

Corrective

Sinus/Septum Problems

Profile Surgery

Chin Implant

Cheek Implant

Facial/Neck Liposuction

Ear Surgery

Reduce Prominence

Reduce Earlobe Size

Repair Torn Earlobe

Skin Rejuvenation

Skin growths/moles

Wrinkles

Pigmentation/Age Spots

Redness/Rosacea

Broken Blood

Vessels

Roughness

Scars

Large pores

Acne

Acne scarring

Other

Injectables

Botox

Collagen

Restylane

Radiesse

Sculptra

Vessels

Juvederm

Other

Other Procedures

Hair Removal

Hair Transplant

Microdermabrasion Peel

Chemical Peel

Spider Veins

Face

Legs

Facial Soft Tissue Augmentation

AREAS

Other

Please indicate in your own words what concerns you

How did you hear about our office?

Friend

Co-Worker

Urban Active(Gold's Gym)

Web Site

Dr./Patient Referral

Elegant Permanent Cosmetics

Salon

P&G credit Union

Newspaper

Radio

TV

Others

Name

Relative

Name

(Which one)

Medical History (check all that applies)

Heart Disease

High Blood Pressure

Heart Attack

Respiratory Condition

Eye problems

Emphysema

Diabetes

Nose problems

Asthma

Cancer

Ear Problems

Blood Disease

Gastro-Intestinal Condition

Bleeding Problems

Jaundice/Hepatitis

Urinary

Thyroid Problems

Anemia

Thyroid Disease

HIV

Facial Trauma

Date of last physical (MM/DD/YYYY)

MM slash DD slash YYYY

Smoking

Yes

No

#packs

per

Alcohol

Yes

No

frequency

per

(drink socially only)

Have you ever consulted a professional for emotional problems?

Yes

No

If yes, What kind? Where?

Allergies

Medications presently taking

Do you take any of the following? (Please check)

Blood Pressure Meds

Vitamin E

Ginko

St. John's Wort

Ginseg

Aspirin

Garlic

Name of drug

Other

General Surgical/ Plastic Surgery History (list all surgeries and indicate any complications)

Any complications from general or local anesthesia for yourself or any relative?

Yes

No

NOTES

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First Name*

Last Name*

Email*

Phone*

Procedure of interest*

Referral Source*

Comments*

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Email

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5 stars from 164 reviews

 5/5

Cincinnati, OH
Dayton, OH
Crestview Hills, KY

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(513) 891-LIFT(5438)

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