Anti-Aging/Future Medicine Patient Application

Anti-Aging/Future Medicine
Form

General

First Name:
(Nombre)

Last Name:
(Nombre)

Date:
(Fecha)

Age:
(Edad)

Address:
(Direccion)

City:
(Ciudad)

State:
(Estado)

Zip Code:
(Codigo Postal)

Phone Home:
(Telefono)

Marital Status:
(Estado Civil)

Sex:
(Sexo)

Date of Birth:
(Fecha de Nacimiento)

Employer:
(Lugar de Empleo)

Occupation:
(Ocupation)

Emergency Contact:
(Contacto de Emergencia)

Relationship:
(Parentesco )

Emergency Phone Home:
(Telefono Emergencia de Casa)

Emergency Phone Work:
(Telefono Emergencia de Trabajo)

Email Address:

(You will be subscribed to our monthly newsletter, you may unsubscribe at any time.)

How did you
hear about us?

TV:

Yes No

What Channel?

Radio:

Yes No

What Station?

OtherSources:

Internet Sites:

Referred by:

Newspaper / Flyer / Magazine:

Health History

Medications:

(prescription and over the counter; vitamins, herbal medications)

Allergies:

Current Medical Diagnosis:
Current/Past Medical or Surgical Problems::
Surgeries /Dates:

Are you?

Pregnant:

Yes No

Nursing:

Yes No

Do you?

Smoke:

Yes No

Drink Alcohol:

Yes No

Amount per day:

Post Treatment Instructions

DO:

Remain upright for 4 hours after injection
Exaggerate facial expressions in injected areas for 1 hour after injection
Call the office immediately if you experience any problems or have any questions
Schedule your follow up appointment prior to leaving office

DO NOT:

Take ibuprofen, aspirin or vitamin E for 24 hours after injection
DO NOT massage or manipulate injection sites for 48 hours after injection
Results are expected within 24 hours to one week after injection

The above information is true and accurate to the best of my knowledge.

Patient Signature:

Date:

Witness Signature:

Date: