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
Emergency Contact
phone #
Referring md name
How Did You Hear About
Primary md name
The Baltimore Center For Plastic Surgery?
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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.
(Turn Over)
Name:
DOB:
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
⃝ Injectables
⃝ Latisse
⃝ Tummy Tuck
⃝ Lip Augmentation
⃝ Chin Surgery
⃝ Liposuction
⃝ Scar Revision
⃝ Hydrafacial
⃝ Laser/ IPL
⃝ Facial Trauma
⃝ Cleft Lip/Palate
⃝ Skin Care – Would you like to meet with our Medical Aesthetician today if possible? YES / NO
Your Health History
Current & 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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Social History:
Occupation:
Marital Status:
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 If Known
Reason
1____________________________________________________________________________________________
2____________________________________________________________________________________________
3____________________________________________________________________________________________
4____________________________________________________________________________________________
5____________________________________________________________________________________________
Medical and/or Environmental Allergies:
⃝ No Known Drug Allergies
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