New Patient Intake Form Step 1 of 9 11% Step 1: Patient InformationPlease be as accurate as possible. Please click on the "NEXT" button at the bottom of the page.Name* First Last Date of Birth* Gender*- Select -MaleFemaleOtherMarital Status*- Select -SingleMarriedWidowedLanguage* Race* Your Contact InformationPhone*Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment InformationEmployment Status*- Select -Not Currently WorkingEmployedSelf-EmployedRetiredOccupation* Company Name* Company Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactName* Relationship* Phone* Step 2: Treatment or Service Interested InPlease check all treatments and/or services you are interested in. Please click on the "NEXT" button at the bottom of the page.Up Top* Hair Restoration Eyebrow Hair Transplant PRP Therapy Rogain / Propecia Capillus Laser Treatment Below The Belt Penis Enlargement Erectile Dysfunction Prostate Health / Exam Laser Hair Removal Other Medical Services VASER Liposuction Dermatology TMS Therapy Primary Care Other Step 3: Past Medical HistoryPlease be as accurate as possible. Please click on the "NEXT" button at the bottom of the page.High Blood Pressure* Yes No Details Heart Disease* Yes No Details Any Chest Pain* Yes No Details Shortness of Breath* Yes No Details Stroke* Yes No Details Asthma* Yes No Details Taking a Blood Thinner* Yes No Details Sleep Apnea* Yes No Details High Cholesterol* Yes No Details Depression or Anxiety* Yes No Details Arthritis or Joint Pain* Yes No Details Bruising or Swollen* Yes No Details Prolonged Bleeding* Yes No Details Unsatisfactory Scars* Yes No Details Mental or Emotional Condition* Yes No Details Herpes or Cold Sores* Yes No Details Blackout Episodes* Yes No Details Abdominal problems* Yes No Details Hepatitis A, B or C* Yes No Details HIV or AIDS* Yes No Details Diabetes* Yes No Details Leg Swelling* Yes No Details Extreme Thirst Or Hunger* Yes No Details Thyroid Condition* Yes No Details Seizures or Slurred Speech* Yes No Details Any Type of Cancer* Yes No Details Allergies?* Yes No Details Any Other Illness or Condition* Yes No Details Step 4: Past Surgical History*Please be as accurate as possible. Click on the "NEXT" button at the bottom of the page*Date of Operation Operation Details Date of Operation Operation Details Date of Operation Operation Details Step 5: Family History*Please be as accurate as possible. Please click on the "NEXT" button at the bottom of the page.*Cardiac Disease* Yes No Details Respiratory Illness* Yes No Details High Blood Pressure* Yes No Details Anesthesia Problems* Yes No Details Diabetes* Yes No Details Abdominal Bleeding* Yes No Details Hepatitis* Yes No Details Skin Cancer* Yes No Details Any Other Cancer* Yes No Details Psychiatric Disorder* Yes No Details Any Other Condition or Illness* Yes No Details Step 6-A: Smoking History*Please be as accurate as possible. Please click on the "NEXT" button at the bottom of the page.*Do You Currently Smoke or Vape?*- Select -YesNoHow Many Packs Per Day?*- Select -N/ALess Than OneOneTwoMore Than TwoDid You Quit Smoking?*- Select -N/AYesNoHow Long Ago?*- Select -N/ALess than 1 year1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 YearsMore than 10 YearsStep 6-B: Alcohol and Drug Use*Please be as accurate as possible. Please click on the "NEXT" button at the bottom of the page.*Do You Currently Drink Alcohol?*- Select -YesNoHow Many Drinks Per Day?*- Select -N/A1 to 33 to 66 to 1010+Do You Smoke Marijuana?*- Select -YesNoDo You Use Any Other Drugs?*- Select -YesNo Step 7: Current Medication(s)*Please be as accurate as possible. Please click on the "NEXT" button at the bottom of the page.*Medications You Are Currently Taking*Please provide the medication name, dosage and frequency. Step 8: Preferred Pharmacy Information*Please enter the name, location and the phone number of the pharmacy you want to on-file *Pharmacy Name* Phone*Pharmacy Address / Location* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Final Step: Photo I.D. and Insurance CardPlease include the front and back of a valid government issued I.D. card and your current insurance card. When finished, click submit at the bottom.Front of Government Issued I.D.*Max. file size: 5 GB.Back of Government Issued I.D.*Max. file size: 5 GB.Front of Current Insurance Card*Max. file size: 5 GB.Back of Current Insurance Card*Max. file size: 5 GB.
