Microsoft word - newpatientinfo.doc

New Patient Information

Name: __________________________
Address: ______________________________________________________ City: _______________________________ State: Home: (____) _______________ Work: (____) ____________ Cell: (____)______________ E-mail: ______________________________________________________________________ Emergency Contact: ____________________ Allergies: ____________________________________________________________________ For women: LMP: ______________________ How did you hear about {Practice Name Here}? _____________________________________ Please put a check mark next to the procedures about which you would like to receive more information: ___ Botox to Flatten and Prevent Wrinkles Please put a check mark next to a past or current medical condition:
Medical History:
___ Lupus or other auto-immune deficiency ___ Herpes simplex or fever blisters (A) Rheumatoid Arthritis “Gold” Therapy (A) ___ Dark spots after pregnancy, skin injury (A) ___ Treatment with Accutane® in the last ___ Treatment with Tetracycline® in the last ___ Waxing/Plucking/Electrolysis within last ___ Transplant Anti-Rejection Drugs (HR) ___ Implants (Location:______________) ___ Collagen injection (Location:_________) Please list any medications or herbal supplements that you are currently taking: ____________________________________________________________________________ Reviewing the Medical Profile

All patients must complete and sign the New Patient Information form prior to treatment. The
medical history is reviewed and confirmed with the patient during their consultation.
All conditions or drugs that ABSOLUTELY PRECLUDE TREATMENT are shown on the left side
of the Medical History section on the New Patient Information form.
Medical History:
___ Lupus or other auto-immune deficiency (A)
___ Currently Pregnant (A)
___ Bleeding abnormalities (A)
___ Treatment with Accutane® in the last
___ Treatment with Tetracycline® in the last ___ Psoriasis or Vitiligo (A)
___ Pulmonary embolism/blood clot (V)
___ Leg ulcer or Phlebitis (V)
___ Blood thinning medication (V)
___ Coumadin/anti-clotting agents (A)
___ Rheumatoid Arthritis “Gold” Therapy (A)
___ Cystic Acne (P)
All conditions or drugs that require patient counseling or additional cautions are shown on the
right side of the New Patient Information form. The clinician should interview the patient for
more details and consult the supervising physician when necessary. For instance, if the patient
is diabetic, the diabetes should be under control and the patient should be cleared for treatment
by their primary care physician.
Medical History:

___ Herpes simplex or fever blisters (A)
___ Diabetes (A)
___ Light Sensitive Epilepsy (A)
___ Scars that turn white or brown (A)
___ Dark spots after pregnancy, skin injury (A)
___ Waxing/Plucking/Electrolysis within last 6 weeks (HR) ___ Hirsutism (HR) ___ Transplant Anti Rejection Drugs (HR) ___ Chemical Peels, Dermabrasion, Laser resurfacing or Face lift (A) ___ Tatoos/permanent make-up ___ Polycycstic ovarian disease (PCOD) ___ Implants (Location:______________) ___ Collagen injection (Location:_________)

Source: http://vasclinic.net/newpatientinfo.pdf