Patient Information Form

Please complete the following form for our records to the best of your ability.
Details of medical history will be kept strictly confidential.

Personal Information
Surname*
First Name*
Middle Initial
Gender*
Date of Birth(DD/MM/YYYY)* //
Family Dr.
House Name
Street Address
Parish
Postal Code
Mailing Address (If different)
Parish
Postal Code
Patient Contact Information
Home Phone*
Business Phone
Cellular Phone
Employer
Occupation
E-Mail Address*
Emergency Contact
Home Phone
Business Phone
Cellular Phone
Other
Medical Insurance
Insurance Company
Group #
Certificate #
Effective Date
Name of Primary Insured
Medical Condition or Illnesses past and present
(e.g.) High Blood Pressure, Heart Disease, Heart Attack, Smoke, High Cholesterol, Kidney, or Liver disease, Diabetes, Asthma, Cancer
Present

Past
Prior Surgeries and Procedures in chronological order, with approximate dates.
(Also include all cosmetic surgeries, Laser resurfacing or chemical peels, and any eye surgeries).
Cosmetic

Non-Cosmetic

Have you ever had any of the following? (check all that apply):
Bleeding during surgery
Anemia
Bad reaction to local or general anesthetic
Cold sores or herpes
Blood clots (e.g. DVT S)
Persistent eye dryness
Other eye diseases/problems  please list
Environment Allergies
Hay fever
Sinus problems
Emotional problems (e.g. depression) - please list
Other eye diseases/problems

Emotional problems (e.g. depression)

Allergies to medications

Current medications Be sure to include birth control pills, inhalers, nasal sprays, over the counter drugs (e.g. aspirin), topical medications, homeopathic remedies and vitamins.
Have you ever taken:
Acutane When?
Retin_A When?
Cigarette smoking - Please check/complete approximately
I have never smoked
I quit smoking in the year:
I currently smoke packs per day. I started smoking in the year
Alcohol Consumption
Never
1 - 5 drinks per week
5 - 14 drinks per week
> 14 drinks per week
When was the last time you had a complete medical examination(MM/YYYY)? /
Do you wear corrective eye glasses or contact lenses? Yes No

Credit Policies Term and Conditions

By submitting this form, I/We agree to the policies, terms and conditions of International Plastic Surgery Associates,

Which are subjected to change on notification from the Corporation Office. I/We agree that all agency charges, legal costs and other expenses incurred by International Plastic Surgery Associates in attempting to recover overdue amounts will be charged to my/our account. I/We give permission to International Plastic Surgery Associates to obtain information from any source to verify any statements made in this application.*