Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Plastic Surgery Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Areas of Concern
Desired Outcome & Goals
Prior Cosmetic Procedures
Body Dysmorphia Screening
Additional details
Medical History & Clearance
Smoking & Nicotine Use
Current Medications & Supplements
| Medication | Dose | How often |
|---|---|---|
Anesthesia History
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Insurance / Self-Pay
Consent & Signature
Date
Plastic Surgery Intake Form template from formisoft.com. formisoft.com/intake-templates/plastic-surgery-intake