Dr. Alexander Donath

1-877-416-FACE(3223)

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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.

Date*
Date Format: 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)
Date Format: 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
Thank you for taking time to complete this important questionnaire.

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Cincinnati Facial Plastic Surgery

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Dayton/Centerville Office

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COSMETIC PROCEDURES

Botox / Dysport
Brow lift
Ear Reshaping
Eyelid Lift
Facelift
Liposonix
Reconstructive
Revision Rhinoplasty
Rhinoplasty
Skin Care Program
Volume Lift^SM: Fat Transfer
Volume Lift^SM: Injectables
More Cosmetic ProceduresMore

Frequent Questions
Just for Patients
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Articles and Blog
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Latest News

Medical Edge

Dr. Donath was featured in Channel Fox 19.

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State of the Art Office!

Cincinnati Facial Plastics recently renovated its office to make it state-of-the-art. See the photos below.

Special Offers

$100 off any in office procedure

No cash value. One procedure per person, new patients only, and cannot be combined with other offers. Skincare excluded.

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Articles

If you could interview any healthcare professional, who would it be and why?

Read what Dr. Donath had to say

Venue magazine article on Dr. Donath's approach to international beauty

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Article in Venue magazine on Dr. Donath's practice

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Dr. Donath's landmark eyelid rejuvenation article

Click here to read excerpts

Dr. Donath named one of Cincinnati’s Top Doctors of 2018!

5 stars - based on 135 reviews
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Locations: Cincinnati, OH | Dayton, OH

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