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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