New Patient Paperwork

Please fill out our New Patient Form below and provide as much information as possible. If we have any further questions you will be contacted accordingly.

Personal Information

Last Name

First Name

Middle Name

Name as it appears on your state-issued ID

Home Address

City

State

Zip Code

Home Telephone

Cell Phone

Work Phone

Other Phone #

Which number should we use to contact you?

HomeCellWorkOther

We make reminders! Would you like to be contacted via phone or e-mail?

PhoneE-Mail

Your E-Mail Address

Birth Date

SSN #

Sex
MaleFemale

Occupation

Employment Information

Employer Name

Employer Phone Number

Employer Address

City

State

Zip Code

Additional Information

Which procedure would you like to discuss today on your visit? Please specify and describe your situation a little bit below in the boxed area.

Referred by

Appointment Date

Appointment Time

Emergency Contact

Name

Relationship

Home Phone

Work Phone

Cell Phone

Parental Signature (Type your full name to sign in field below):

Date

Health Information

Name

Age

Primary Physician

Gynecologist

Date of Last Physical Exam

Date of Last Mammogram

Pants/Dress Size

Bra Size

Are you taking any medications on a regular basis or any within the past 12 months? (Include Aspirin/Vitamins) (If Yes, please list in box to the right.)
YesNo

Are you taking birth control or using Intrauterine Devices or on Hormones? YesNo

Are you allergic to or ever had any reaction to any medications, drugs or local anesthetic? (Including Novocaine, Xylocaine, Latex, soaps, lotions, tapes, etc.) (If Yes, please list in box to the right.)
YesNo

Have you ever had an operation or been hospitalized for any reason? (If Yes, please provide Date, Reason, and Physician in the box to the right.)
YesNo

How many pregnancies have you had?

How many births have you had?

Have you ever had rheumatic fever, heart trouble, heart murmurs, palpitations, irregular heartbeat, chest pains, high blood pressure, shortness of breath, swelling of the ankles?
YesNo

Have you ever had diabetes, hepatitis, cancer, thyroid disorder, kidney problems, asthma, chronic lung or bronchial disease, or any other serious illness?
YesNo

Have you or anyone in your family ever been diagnosed and/or treated for bleeding disorder, blood clots, excessive bleeding, Deep Venous Thrombosis (DVT), or Pulmonary Embolism?
YesNo

Have you ever had a fractured nose, difficulty breathing, nose bleeds, post nasal drip, hay fever, deviated septum, sinus pain?
YesNo

Have you ever had eye disease, trouble with dryness, soreness, burning, itching, excessive tearing of the
eyes?
YesNo

Have you ever had any psychiatric problems, nervous breakdown, presently or have you ever been under the care of a psychiatrist?
YesNo

Do you have any problems with excessive scarring, or have you ever formed a keloid after being cut? YesNo

Do any diseases run in your family? (Please answer Yes or No. If Yes, use box below to provide details.)
YesNo

Is there any additional health information you feel you may need to discuss with us? (If Yes, please use box below to provide details.)
YesNo

Do you have a problem with alcohol or chemical dependency?
YesNo

Do you use any Nicotine containing products? (i.e.: patches, gum)
YesNo

Do you smoke Cigarettes or Vapor/electronic cigarettes?
YesNo

How many cigarettes or vapor/electronic cigarettes do you smoke?
(Please explain briefly in box below.)

Payment Policy

We strive to provide all of our patients with prompt and excellent medical care and to assist you in the handling of your bill. In order to maintain your account in good standing, our requirements for payment of your account are as follows:

PAYMENT IS EXPECTED FOR ALL OFFICE VISITS, SERVICES, TREATMENTS, AND PRODUCTS AT THE TIME OF EACH VISIT.
ALL CHARGES ARE DUE AND PAYABLE THE DATE THEY ARE INCURRED
We do not accept the theory that legal cases should be settled before payment of the fee is due. ALL CHARGES ARE DUE AND PAYABLE THE DATE THEY ARE INCURRED.

Because our services are rendered to YOU, you are responsible directly to us for settlement of your account within the time limit set. Please feel free to discuss your bill or charges at an early date, to avoid misunderstandings.

It is understood that failure to comply with this agreement would leave St. Louis Cosmetic Surgery, Inc. no alternative but to seek collection action.

The quote that you receive at your consult will include the doctor’s fee, plus OR and anesthesia. Payment of these fees will be due prior to surgery.

We do not accept or file insurance claims. Our services are not covered by insurance.

Signature (Type your full name to sign in field below):