New Patient Information

PLASTIC AND RECONSTRUCTIVE SURGERY

521 Park Avenue
New York, NY 10065
P: 212.448.7450 F:212.734.9831
New Patient Information
Date:*

MonthDay Year
Date
Name:*
Date of Birth:*

MonthDay Year
Date
Age:*
Sex:*
Marital Status:
Email:*
example@example.com
Address*

Address

Street Address Line 2

City/State/Zip# State / Province

Postal / Zip Code
Home Phone:
Cell Phone:*
Occupation:*
Employer:
Work Phone:
Spouse/partner name:*
Spouse/partner phone:*
Who may we thank for referring you to our office?*
What is the name and phone number of your medical doctor?*
Pharmacy Information
Preferred pharmacy (name and phone):*
Health Information
Do you smoke cigarettes?*

YesNo
Drugs to which you are allergic (what happens?):*
Are you allergic to any of the following?*

Adhesive tapeLatexOpiates (codeine, Percocet)AspirinAntibioticsLocal anestheticsSulfaIodineNone
Medications, vitamins, and supplements you take now:*
Please list any plastic surgery you have had, including approximate dates:*
Please list any medical problems, including approximate dates of diagnosis:*
Please list any other surgeries you have had, including approximate dates:*
Have you been diagnosed with any of the following:

Blood clot (deep vein thrombosis, Pulmonary embolism)

Have you been diagnosed with any of the following:*

	NO	YES	IF YES, please describe
High Blood Pressure
Heart Attack
Stroke of TIA (mini-stroke)
Blood clot (deep vein thrombosis, Pulmonary embolism)
Bleeding problems
Cancer
Kidney problems
Seizures
Psychiatric condition
Problems with anesthesia

Please describe what you would like to discuss with Dr. Levine:*
Thank you for taking the time to fill out this form. I look forward to meeting you.
Patient Signature:*

Clear
Date:*

MonthDay Year
Date
Reviewed by Dr. Levine:
Date:

MonthDay Year
Date
Should be Empty: