Date of Birth
Subject to my suitability, I wish to have the following procedures:
Face lift Neck lift superior blepharoplasty inferior blepharoplasty rhinoplasty otoplasty neck liposuccion Chin augmentation
GENERAL MEDICAL HISTORY
Please provide the following information:
Tick if any of the following apply to you?
Diabetes Epilepsy High Blood Pressure Hemophilia or other clotting disorder? AIDS Hepatitis Mitral valve prolapse or implant Pacemaker Heart Palpitations Pregnant or Nursing Currently on blood thinners or anti coagulants such as Aspirin, Ibuprofin, Coumadin Rheumatic fever Smoking
Are you currently under medical supervision for any disorder ?
Doctors name, phone number and email:
Please list any medications, over-the-counter or prescribed taken in the past month:
Have you had any surgery? Please give full details :
This is a true and accurate statement of my medical history, past and present. I am aware that failure to disclose information pertinent to my treatment could have serious health ramifications. I am also aware that failure to disclose information pertinent to my treatment could have a direct bearing on treatment outcome.
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