NEW PATIENT INFORMATION. Name: Birthdate: / / Age: Home: ( ) Cell: ( ) Work: ( ) Employer: Occupation: How did you hear about Dr. Lambros?
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1 NEW PATIENT INFORMATION Today s Date Marital Status Name: Birthdate: / / Age: Address: Sex: M / F City: State: Zip Code: Home: ( ) Cell: ( ) Work: ( ) Employer: Occupation: Spouse: Emergency Contact: Telephone: ( ) Telephone: ( ) How did you hear about Dr. Lambros? Please check the procedure about which you would like to receive more information: Facial Rejuvenation; Face / Neck lift, Correction of Eyelids, Chin Augmentation, Fat Injection Botox / Dysport Breast Enhancement Fillers; Juvederm, Restylane Body Contouring Please list any current Medical Conditions: Please list all Medications, prescribed or over-the-counter, and Vitamins that you are currently taking: Do you have allergic reactions to any medication? YES/NO
2 Name: Today s Date: Height: Weight: lbs. Please check if you have ever been treated for, or told that you have any of the following: Y N Y N Y N Heart Trouble Nervous Disorder Hemorrhoids Heart Attack/Heart Pain Insomnia Thyroid Diseases Stroke Drug Addiction/Habit Diabetes Hypertension AIDS/HIV Infection Skin Disorders Blood Pressure Abnormalities Herpes Arthritis Rheumatic Fever Cancer Bleeding Tendency/Disorder Digitalis Treatment Glaucoma or Eye Disorder Breast Disease Shortness of Breath Hepatitis Kidney Disorder Chest Pain Gall Bladder Trouble Blood Transfusion Asthma Cirrhosis of Liver Blood Infection Bronchitis Alcoholism Seizure Disorder Tuberculosis Ulcers Malignant Hyperthermia Pneumonia Gastritis Abnormal Reaction to Anesthetics Emphysema Colitis History of MRSA infection Hay Fever Problem Constipation Nervous Breakdown Tarry or Bloody Bowel 1. YES / NO Do you have any family history of cancer, heart trouble, stroke or malignant hyperthermia? 2. YES / NO Do you smoke? If yes, how much 3. YES / NO Do you consume alcohol? If yes, how often? 4. YES / NO Are you pregnant? When was your last menstrual period? 5. When was your last physical examination? 6. Did your last physical examination include an E.K.G.? YES / NO 7. YES / NO Do you have a history of excessive bruising or bleeding following surgery or minor trauma? 8. YES / NO Do you have a history of cold sores? 9. Have you ever had cosmetic surgery? Or been hospitalized? If yes, please list:
3 PATIENT INFORMATION HIPAA COMPLIANCE Please list your preferred method of communications from our office to you. We also need your permission to leave messages for you pertaining to your appointments and care from our office. Home: ( ) Yes No Work : ( ) Yes No Cell : ( ) Yes No Ok to text? Yes No Yes No Date: Signature
4 COSMETIC INJECTION PATIENT CONSENT Introduction: This informed consent document outlines most of the common and uncommon risks involving cosmetic injections. Other risks are possible. Once you have read and understood this information, and had the opportunity to ask questions and discuss any concerns with Dr. Lambros or his staff, please sign and date below. Goals: The underlying goal of injectable treatments is facial rejuvenation: reducing wrinkles, restoring volume, improving facial contours, etc. The specific goals for your treatment should be clarified by discussion with Dr. Lambros or his staff prior to signing this form. Alternatives to injections include no treatment, skin care, laser resurfacing, chemical peels, facelifts and other surgical therapies, and other modalities. Risks: Every procedure (surgical or non-surgical) involves risks that can only be completely avoided by foregoing treatment. Determining whether or not a procedure is right for you depends on your evaluation of the risks, benefits, goals, alternatives, and recovery associated with the procedures. Products may be used in areas that are considered "off label" by the drug manufacturer. These may vary and you may want to discuss this with Dr. Lambros prior to injection. 1. Bruising. One of the most common risks of injection is bruising. Bruises generally resolve in 2-3 weeks and can often be concealed by cosmetics in less than a week. Please avoid aspirin, NSAIDs (e.g., Motrin/Advil/ibuprofen, naproxen), Vitamin E, fish oil, omega-3 fatty acids for 1-2 weeks prior to injection, since these and other supplements may contribute to bleeding. Please inform us of any supplements or medications you take prior to injection, especially Coumadin, or Plavix. 2. Bumpiness (nodularity). Patients often feel some bumpiness, firmness, or tightness under the skin at the site of filler injections. Usually, this is not visible and resolves in 1-2 weeks. 3. Swelling. Swelling is common after injections but is usually mild and localized to the site of injection. If it becomes excessive or painful after the injection, please notify Dr Lambros or his staff. 4. Allergic reaction. True allergic reactions are rare after injectable treatments, but notify us if you develop excess swelling or redness, a rash (especially hives), unusual swelling or airway symptoms. 5. Infection. Infections are rare after cosmetic injection, but please notify us if you develop excess redness, swelling, pain, any drainage, or fever after injection. 6. Skin necrosis. Skin necrosis occurs when a patch of skin dies because of blocked blood flow. The skin typically becomes discolored (pale, bluish, or purple), then scabs over. Affected skin may be painful. Notify Dr. Lambros or his staff if you notice any of these signs; however,
5 these findings are usually noted immediately after an injection. Any affected area will scar. This is a rare complication but can be severe. 7. Blindness. Permanent blindness is a rare complication of any facial injection (cosmetic or medical) but has been documented. This would be noticed immediately upon injection. This may also be more common with permanent fillers. 8. Ptosis. This is a risk only for botulinum toxins (e.g., Botox and Dysport ). It occurs when the botulinum toxin diffuses into the muscle that elevates the eyelid. This is temporary, usually lasting 2-4 weeks. This occurs less than 1% of the time. 9. Headache. Injections occasionally precipitate headaches, usually in patients prone to headache. 10. Granulomas. Inflammation around filler material can cause inflamed red bumps to appear in the skin. This is unusual but is more common with permanent fillers. This may present weeks or months after injection. Other risks are possible. Please ask Dr. Lambros or our staff if you have any questions. Consent: I acknowledge that I have read the foregoing informed consent, have had the opportunity to discuss any questions that I have, and consent to cosmetic injections. I understand that I have the right not to consent to this treatment. I hereby release the doctor, the person performing the injection, and the facility from liability associated with this procedure. Print Name Patient Signature Date
PATIENT REGISTRATION FORM
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PATIENT DEMOGRAPHIC SHEET
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