Cosmetic Surgery Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Address
Phone
Email
Emergency Contact Name
Emergency Contact Phone
Relationship to Patient
Medical History
Primary Physician
Allergies
Current Medications
Past Illnesses & Surgeries
Family Medical History
Lifestyle Information
Do you smoke?
No
Yes
Occasionally
Do you drink alcohol?
No
Yes
Occasionally
Physical Activity Level
None
Light
Moderate
Active
Surgery Information
Procedure Interested In
Reason for Surgery
Patient Expectations / Desired Outcome
Additional Comments