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& T R E A T M E N T
Name: #Name?
Home Phone: #Name?
Chart Number: #Name?
Email Address: #Name?
Physician: #Name?
I hereby consent to and authorize examination and treatment by the physicians at La Jolla Cosmetic Surgery Centre and such assistant and/or staff as may be assigned by him/her.
I understand that photography is a necessary part of planning and evaluating cosmetic or reconstructive surgery. I authorize taking of photographs at the direction of my physician and under such conditions as may be approved by him/her. These photographs will be used solely for documentation purposes and will be kept confidential.
I understand that La Jolla Cosmetic Surgery Centre is primarily a cosmetic surgery practice, and as such are not providers under any insurance plans nor providers under Medicare or MediCal. Payment for all surgery is the sole responsibility of the patient and full payment is required in advance.
SIGNATURE:____________________________________ DATE:___________________________ RELATIONSHIP: (circle one) PATIENT SPOUSE PARENT GUARDIAN C A L / S U R G I C A L H I S T O R Y
In this time of rapidly expanding medical knowledge and the increasing specialization associated
therewith, there exists a very real risk of the specialist physician not being aware of the general health
and medical background of the patient. On occasion such information may critically affect what
procedures we may safely undertake on you and under what circumstances. We therefore ask that you
give us the following medical information.

Please list all prescription medications which you are currently taking or have used in the past 6 months (be sure to include any of the following: birth control pills, aspirin or ibuprofen containing drugs, diet pills, diabetic medications, steroids, glaucoma drops, asthma medications, Digoxin, Lanoxin, nitroglycerin, Isordil, Inderal, other heart medications, Lasix, other diuretics, high blood pressure medications, Coumadin, Persantine, tranquilizers, sleeping pills, anti-depressants, pain pills or shots, epilepsy medications).
List all non-prescription vitamin & herbal medicines: Regular use of recreational drugs? YES/NO If so, please list:Last used: Are you a smoker? YES/NO Ex-Smoker YES/NO Non-Smoker YES/NO How much are (were) you smoking? How long? Quit how long ago? Please circle all of the following medical conditions you now have or have had in the past:AIDS / Allergies (Food or Drug) / Anemia / Asthma or Wheezing / Bleeding Tendency / Blood Transfusion /Bronchitis / Cancer of __________ / Chest Pain / Chronic Cough / Deep Vein Thrombosis / Depression / Diabetes / Drug or Alcohol Addiction / Dry Eyes / Emphysema / Epilepsy or Seizures / Gastric Reflux /Glaucoma / Heart Disease / Heart Attack / Heartburn / Hepatitis A, B or C / Herpes of __________ / Hiatal Hernia / High Blood Pressure / HIV positive / Intestinal Ulcers or Bleeding / Irregular Heart Beat / Latex Allergy / Liver Disease / Lung Disease / Mental Illness / Motion Sickness / Shortness of Breath / Thyroid Disease / Tuberculosis / Stroke / Other /__________ / None of the Above Is there any possibility that you may be pregnant at this time? YES/NO List all surgeries that you have had (include plastic surgery): Date: Have you or anyone in your family ever had unusual reactions to anesthesia (muscle weakness, jaundice, breathing problems or unexpected fevers? YES/NO Do you have (circle): loose or chipped teeth/caps/dentures/contact lenses/None Have you ever seen a cardiologist? YES/NO Physician Name:

Source: http://www.5pints.net/samples/ljcsc/pdf/forms.pdf

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