Patient Intake Form 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment InformationEmployment Status*- Select -Not Currently WorkingEmployedSelf-EmployedRetiredOccupationCompany NameCompany Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactNameRelationshipPhone 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 Medical Consultation 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*YesNoDetailsHeart Disease*YesNoDetailsAny Chest Pain*YesNoDetailsShortness of Breath*YesNoDetailsStroke*YesNoDetailsAsthma*YesNoDetailsTaking a Blood Thinner*YesNoDetailsSleep Apnea*YesNoDetailsHigh Cholesterol*YesNoDetailsDepression or Anxiety*YesNoDetailsArthritis or Joint Pain*YesNoDetailsBruising or Swollen*YesNoDetailsProlonged Bleeding*YesNoDetailsUnsatisfactory Scars*YesNoDetailsMental or Emotional Condition*YesNoDetailsHerpes or Cold Sores*YesNoDetailsBlackout Episodes*YesNoDetailsAbdominal problems*YesNoDetailsHepatitis A, B or C*YesNoDetailsHIV or AIDS*YesNoDetailsDiabetes*YesNoDetailsLeg Swelling*YesNoDetailsExtreme Thirst Or Hunger*YesNoDetailsThyroid Condition*YesNoDetailsSeizures or Slurred Speech*YesNoDetailsAny Type of Cancer*YesNoDetailsAllergies?*YesNoDetailsAny Other Illness or Condition*YesNoDetails Step 4: Past Surgical History*Please be as accurate as possible. Click on the "NEXT" button at the bottom of the page*Date of OperationOperation DetailsDate of OperationOperation DetailsDate of OperationOperation 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*YesNoDetailsRespiratory Illness*YesNoDetailsHigh Blood Pressure*YesNoDetailsAnesthesia Problems*YesNoDetailsDiabetes*YesNoDetailsAbdominal Bleeding*YesNoDetailsHepatitis*YesNoDetailsSkin Cancer*YesNoDetailsAny Other Cancer*YesNoDetailsPsychiatric Disorder*YesNoDetailsAny Other Condition or Illness*YesNoDetails 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 TakingPlease 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 NamePhonePharmacy Address / Location Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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.*Back of Government Issued I.D.Front of Current Insurance CardBack of Current Insurance Card