Patient Information
Name
DOB
SS#
Address
City
State
Zip
Phone –please list at least 2 contact numbers + circle the best number to be reached
Cell
Home
Work
Email address
Occupation
Marital Status
Emergency Contact
Phone #
Referring MD Name
Primary MD Name
Health Insurance Information
Please bring Your Insurance Card(s) and Photo I.D. to the Check-In Desk to be scanned and entered
into Our System. We will take a photo for identification purposes at the reception desk.
Aesthetic Interests:
What Other Services Might Interest You? Circle all that apply.
Facial Rejuvenation (eyelids, face, neck, brow) CoolSculpting®
Rhinoplasty Consultation/Nasal Contouring
Facial Trauma
Breast Augmentation/Lift
Tummy Tuck
Chin Surgery
Liposuction
HydraFacial
Injectables
Scar Revision
Laser/ IPL
Latisse
Cleft Lip/Palate
Lip Augmentation
Skin Care – Would you like to meet with our Medical Aesthetician today if possible?
YES / NO
How Did You Hear About
The Baltimore Center For Plastic Surgery?
_________________________________________________________________________________________________
Name:
DOB:
Your Health HistoryCurrent & Past Medical Conditions: Please list ALL problems or conditions from birth – present.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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Past Surgical History: Please list ALL operations or surgical procedures from birth – present.
____________________________________________________________________________________________________________
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Tobacco Use: Former / Never/ Current some days / Current every day
Alcohol Use: None / Rarely / Moderately / Heavy
*If Former or Current Tobacco User – What age did you start? _____ What age did you stop? ______ How many packs per
day?_______
Current Medications/Vitamins/Herbal Supplements
Dosage/Amount
Reason
1__________________________________________________________________________________________________________
2__________________________________________________________________________________________________________
3__________________________________________________________________________________________________________
4__________________________________________________________________________________________________________
5__________________________________________________________________________________________________________
Have you ever been on Accutane?
No
Yes – When did you start/stop? _____________________________________
Medical and/or Environmental Allergies :
What is the reaction to this allergy?
___________________________________________________________________________________________________________
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I have completed my health history form to the best of my knowledge. I also understand this
information is crucial to treatment alternatives offered to me and/or decisions about my care at
The Baltimore Center.
Signature_________________________________________________
Date______________________