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.
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