Date of Birth
Current Health Conditions
Past Medical History
Bleeding or Clotting Disorder
Irregular Heart Rhythm
Family History of Anesthesia Reaction
Difficulty with anesthesia
None of the above
Additional Medical History (if none type n/a)
Past Surgical History (if none type n/a)
Are you currently taking any medication?
Do you have any medication allergies?
Please List Medicine, Food, and Enviromental Allergies
Do you use or do you have history of using tobacco?
Date You Stopped Smoking
Do you use or do you have history of using illegal drugs?
How often do you consume alcohol?
Surgeons Name and Location and Procedure
Desired Private Nursing Recovery Package (4, 8, 12, 18, 24, etc.) If not scheduling private nursing please put n/a.
If scheduling an initial In-Office Lymphatic Massages, please list the date you are requesting for your initial appointment. Initial Appointments are available Tuesday-Saturday.
What procedure(s) will you (or did you) have performed?
Surgery Time (If Known)
Favorite Music or Musician
Favorite Scent (candle or aromatherapy)
Favorite Fruit or Drink Flavor
Anything else that we need to know to insure that you have an optimal recovery experience:
How did you find us?
Should be Empty: