Plastic Surgery Intake Form
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Plastic Surgery Intake Form
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The Plastic Surgery Intake Form is specifically designed for plastic and cosmetic surgery practices, capturing the detailed aesthetic and medical history that plastic surgeons need for safe, satisfying outcomes. This template collects patient demographics alongside a comprehensive consultation questionnaire covering areas of concern, desired outcomes, realistic expectations, prior cosmetic procedures (surgical and non-surgical), satisfaction with previous results, and a body dysmorphia screening questionnaire to identify patients who may benefit from psychological evaluation before proceeding with surgery.
Built for cosmetic surgery, reconstructive surgery, hand surgery, and body contouring practices, this form includes sections for relevant medical history (bleeding disorders, keloid tendency, autoimmune conditions, wound healing problems), current medications including blood thinners and supplements that affect coagulation, smoking and nicotine use (critical for flap viability and wound healing), anesthesia history and complications, BMI and weight stability documentation, and photo consent authorization for before-and-after documentation. The reconstructive section captures insurance pre-authorization details and referral information.
All fields are HIPAA-compliant and structured for the plastic surgery consultation workflow. The comprehensive pre-visit documentation allows the surgeon to review the patient's goals, medical clearance status, and prior procedure history before the consultation. This enables more focused discussion of surgical options, risks, and expected outcomes during the office visit. The photo consent and body dysmorphia screening support ethical practice standards in cosmetic surgery.
What's included
- Cosmetic goals and expectations assessment
- Prior cosmetic procedure and satisfaction history
- Body dysmorphia screening questionnaire
- Medical clearance and wound healing risk factors
- Anesthesia history and medication review
- Photo consent and before-after documentation authorization
- Consent agreement with e-signature
- Medical conditions checklist
- Structured medication list with dosage and frequency tracking
Who uses this template
- Cosmetic and aesthetic plastic surgery practices
- Reconstructive surgery and microsurgery centers
- Body contouring and post-bariatric surgery clinics
- Hand surgery and craniofacial surgery programs
All form fields
15 fields across 3 pages. Customize any field after signing up.
How to use the Plastic Surgery Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Plastic Surgery Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Plastic Surgery Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 15 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Plastic Surgery Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Plastic Surgery Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 15 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Plastic Surgery Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Plastic Surgery Intake Form for your practice. Set up in minutes.
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