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: *

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Name: *
Date of Birth: *

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

Address

Street Address Line 2

City/State/Zip#
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? *

Yes No
Drugs to which you are allergic (what happens?): *
Are you allergic to any of the following? *

Adhesive tape Latex Opiates (codeine, Percocet) Aspirin Antibiotics Local anesthetics Sulfa Iodine None
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.
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