Please Print & Fax or Bring to Appointment
4 Park Center Court, Suite 100, Owings Mills, Maryland 21117
tel: 410-484-8860 • fax: 410-484-2566
The information on this form is essential for us to review so that we may evaluate your entire suitability and safety for Plastic Surgery. Naturally, all information is strictly confidential. Your time and effort to accurately fill out this form is much appreciated. Thank You!
Date________________________
Patient's Name________________________________________Age_____Date of Birth_________________________
Address____________________________________City____________________State________Zip______________
Phone________________________________________(cell)________________________________________
Married____Single____Widowed____Other____Sex (M)____or (F)____
Cell Phone________________________
Occupation________________________________________Employer_______________________________________
Work Address & Zip____________________________Phone_________________Soc. Security No._______________
Your e-mail address:________________________________________________________
Have you, or a family member, ever been to Dr. Vogal's office for consultation?_________________________
Who referred you? |
____Doctor:______________________________________
____Yellow Pages ( )One Book ( ) Verizon
____Another Patient: Name Please:_________________________________________________________________
____Other:______________________________________________________________________________________
May we send a thank you note to this referring source? Yes______No______
Emergency Contact:_________________________________________Relationship:___________________________
Home Phone:_________________________Work Phone:______________________Other #:_____________________
PRESENT INTEREST
Your Area of Interest in Plastic/Cosmetic Surgery____________________________________________________
ALLERGIES TO: MEDICATIONS?Yes_______No_______Which Ones? _______________________________
Latex?Yes_______No_______ADHESIVE TAPE? Yes_______No_______
If yes to medicines/latex allergies, please describe reaction______________________________________________
PAST MEDICAL HISTORY
General Health: Good______ Fair______ Poor______
If Not Good Please Explain_________________________________________________________________________
Do You Smoke? Yes______ No______ How Many Packs A Day? _________ For How Long?____________________
PREVIOUS SURGERY(please list on the back of this sheet if additional room is needed)
Operation Year Hospital City Surgeon's Name Anesthesia?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Complications After Surgery? Yes______ No______ If Yes, Explain______________________________________
Have you ever had nausea after surgery or a tendency to have motion sickness or get car sick? Yes _____No ____
If yes, please explain_________________________________________________________________________
PRESENT HISTORY
Height_________________ Weight__________________ Date of Last Physical Exam_________________________
Name and Address of Family Doctor_________________________________________________________________
Serious Illness? (please list)________________________________________________________________________
Is there any possibility that you may be pregnant at this time? Yes_______ No_______
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
PREOPERATIVE INFORMATIONI certify that the information I have provided is correct. l I realize that I am fully responsible for payment in full to James E. Vogel, MD for services rendered. I understand that all fees are due in advance of treatment or on the day of treatment depending on the nature of the service or procedure. I understand that a patient bill of rights is available for me to read if requested.
Form Keloids_____ Bruise/Bleed Easily_____ Migraines_____ Acid Reflux/GERD_____ Thyroid_____
High Blood Pressure_____ Heart Disease/Heart Attack_____ Diabetes_____ Anemia_____ Seizures_____
Lung Disease_____ Kidney Disease_____ Asthma_____ Sleep Apnea/Breathing Problems_____
Anxiety/Depression_____ Sinus Allergies_____ Hepatitis B or C_____ Any other:___________________________
_______________________________________________________________________________________________
VERIFICATION OF INFORMATION AND POLICIES: Have you ever had any of the following? (Answer: Yes or No)
Signature__________________________________________________Date__________________________________