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* 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 Thank you for taking time to complete this important questionnaire. Click here to download Patient Health History By submitting this form I agree to the Terms of Use Phone This field is for validation purposes and should be left unchanged. Δ Donath Facial Plastic Surgery Dayton/Centerville Office
