Patient Information
Name
dob
SS#
state
zip
Address
City
Phone – please list at least 2 contact numbers, circle the best number to be reached
and leave messages regarding appointments/information
(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? Check all that apply.
⃝ Facial Rejuvenation (eyelids, face, neck, brow)
⃝ CoolSculpting®
⃝ Rhinoplasty Consultation/ Nasal Contouring
⃝ Breast Augmentation/Lift
⃝ Chin Surgery
⃝ Tummy Tuck
⃝ Injectables
⃝ Lip Augmentation
⃝ Latisse
⃝ Hydrafacial
⃝ Liposuction
⃝ Scar Revision
⃝ Laser/ IPL
⃝ Facial Trauma
⃝ Cleft Lip/Palate
⃝ 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?
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Name:
DOB:
Your Health HistoryCurrent & Past Medical Conditions: Please list ALL problems or conditions from birth – present.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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
Medical and/or Environmental Allergies :
Yes – When did you start/ stop?______________________________________________
What is the reaction to this allergy?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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______________________