Cosmetic Intake Form-Dr.David Rankin

ABOUT DR. DAVID RANKIN-

Cosmetic and reconstructive surgery is where “art” and “science” blend to combine intuition, creativity and artistic sense with extensive surgical training, discipline and medical knowledge.

Dr. Rankin is a Board Certified Plastic and Reconstructive Surgeon specializing in cosmetic surgery and upper extremity surgery. He also has specialized training in reconstructive surgery for birth defects, traumatic injuries and deformities from cancer including microsurgery and breast reconstruction.

Dr. Rankin is committed to fully educating his patients about their individual procedures and will spend the time necessary to discuss all possible techniques and alternatives. His goal is to provide exceptional and natural appearing results on a consistent basis. He is privileged to have a diverse patient base from all parts of the United States and from numerous countries around the world.

In his quest to ensure that his patients receive the benefit of the latest technologies and advances in cosmetic and reconstructive surgery, Dr. Rankin routinely attends seminars, training and continuing medical education courses.

Name: *

First Name Last Name

SSN:

DateTime *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Birth Date *

Month Day Year

Age *

Sex: *

Height: *

Weight: *

Cell Phone Number:

Home Phone Number:

Email Address:

Occupation:

Name of Employer:

Employer Address:

Employer Phone Number:

In Case of Emergency Notify: *

How is this person related to you? *

Emergency Contact Phone Number: *

May we send you email including news and specials about the practice?

Yes No

May we request you on Facebook?

Yes No

Family Doctor:

Where is your family doctor located?

How were you referred to our office?

What is reason for your visit today? (Your concerns are very important to us. Please describeany concerns you would like the doctor or staff to discuss with you today) *

Have you consulted with any other physician about this? If yes, whom?

List all Medications you currently take including Herbal Supplements/vitamins? *

List any Allergies you have: *

List past & current Medical Problems:

Describe all prior Hospitalizations & dates:

Past Surgical History-List any Surgeries you have had & dates:

Social History

Do you smoke? *

If yes, how many cigarettes/day? *

Did you smoke in the past? *

If yes, how many for how long? *

Do you drink alcohol? *

If yes, how many drinks per week? *

Do you take drugs not prescribed by a Doctor? *

Past/Current Medical History (check all that applies and describe above) *

Review of Systems

Select any of the following that you have had recently: *

Do you scar easily, or are you prone to hypertrophic or keloid scarring?

If you were injured, did it occur at work?

Family History: Is there any history of medical problems in your family? (For women, please include any historyof breast cancer or disease)

Females: (if applicable)Are you pregnant or possibly pregnant?

# of Pregnancies

# of Children

Do you have any history of breast disease or breast cancer?

Do you have any acute or chronic Breast Pain, Lumps, Discharge?

What was the date and findings of your last mammogram?

Have you had Radiation Therapy and/or Chemo Therapy in the past?

Please Describe:

Radiation/Chemotherapy

Past Anesthesia History : Have you had Anesthesia in the past?

What type of anesthesia?

Describe any problems you've had with anesthesia?

Are you interested in learning more about any of the following Aqua Med Spa procedures:

The web is becoming a key way patients learn about our practice. Do you participate inany of the following? (check all that apply)

Yelp Facebook Twitter Instagram Snapchat Realself Blogging

What website(s) did you find helpful to use in researching our practice or theprocedure?

Notice of Privacy Practices Acknowledgement

I have reviewed a copy of Dr. Rankin’s Notice of Privacy Practices.
(If you desire a printed copy of the notice, please notify the receptionist. )

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