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Patient Form Test

Maximize your first visit

Please fill out the patient registration forms provided below prior to your first appointment. If you have any questions or need assistance, call us at 480-800-4501 or contact us.

Required fields are highlighted & marked with *

    • 1

      Patient Information

    • 2

      Cosmetic Treatments

    • 3

      Medical History

    • 4

      Pictures

    • 5

      Send

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    Patient Information

    Patient Information

    1. First Name (*)

    2. Middle Initial

    3. Last Name (*)

    4. Email (*)

    1. Cell Phone (*)

    2. Home Phone

    3. Work Phone

    4. Preferred Phone

    5. Occupation

    6. SSN

    1. Sex (*)

    2. Height (*)

    3. Weight (lbs) (*)

    4. Date of Birth (mm/dd/yyyy) (*)

    5. Age (*)

    6. # of Children (*)

    7. C-Section

    1. Please list your main interests / concerns (*)

    2. How did you hear about Infini?(*)

    Home Address (*)

    1. Home Address (*)

    2. City (*)

    3. State (*)

    4. Zip (*)

    Mailing Address

    1. Mailing Address

    2. City

    3. State

    4. Zip

    Emergency Contact (*)

    1. Name (*)

    2. Phone (*)

    3. Address

    4. City

    5. State

    6. Zip

    Authorization

      Due to the new HIPAA laws that are now in effect, we must have your written authorization to release your medical information to a person other then yourself. Understand that your information may need to be discussed with your current physician or any other member of your physician’s office and/or other medical facility in regards to the scheduling of procedures. Only the information needed to do this will be released. This release will be valid for one year from the date of signing.

      Whon may we release your medical information to: (*)

    1. Spouse

    2. Sibling

    3. Parent

    4. Son/Daughter

    5. Physician

    6. Attorney

    7. Other

    1. May we send you any correspondence through the mail?

    1. May we leave a message on your answering machine confirming appointment or following up on any procedures done in our office that you need to call us about? (*)

    Cosmetic Treatments

      I am interested in the following:

    1. Body Sculpting

    2. Choose Your Liposuction Areas of Concern
      Please be as specific as possible

    3. Why are you considering Liposuction?

    4. Injectables

    5. Lasers / Skincare

      Have you had previous cosmetic surgeries (*)?
      Have you had any OTHER cosmetic procedures (*)?

    1. Please list any bad outcomes

      Pigment Type - How do you tan? (*)

    1. I. Burn AlwaysII. Usually BurnIII. Sometimes BurnIV. Rarely BurnV. Never Burn

    1. Ethnicity (*)

    2. History of Skin Cancer

    3. Type

    Medical History

      Please fill out each section of the medical history form. If you have had no medical problems choose [no problems].

    1. Heart and Vascular*

    2. Lungs*

    3. Nervous System*

    4. Blood and Coagulation*

    5. Musculo-Skeletal System*

    6. Urinary/Reproductive*

    7. Gastro-Intestinal*

    8. Miscellaneous*

    1. Other Medical Problems or Disease (VERY IMPORTANT):

    2. Past Surgical History (Non-Cosmetic):

    3. Current Medications (Please list medication, dosage, how often you take them and for what medical condition):

    4. Allergies (and type of reaction):

    1. Pregnant or nursing?YesNo

    2. AlcoholYesNo

    3. TobaccoYesNo

    4. History of fever blisters (cold sores)?YesNo

    Photos

    Please take photos in front of a plain background. For example, use a plain-colored wall or plain-colored sheet (white or blue is preferable) hung on a wall.

    HIPPA Acceptance *

    I acknowledge that I have read & understood the Notice of Privacy Practices [HIPPA Form]

    Patient's Rights & Responsibilities *

    I acknowledge that I have read & understood the [Patient's Rights & Responsibilities Document]

    Signature (*)


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