Medical form

Patient first name, last nameAgeDate of BirthHealth Insurance CardExpiration dateAddressPhone numberYour email addressName and telephone number of the contact person in case of an emergencyHow did you hear about usReason for Visit List all medication that you are presently taking (including creams, ointments or drops, vitamins, supplements and any homeopathic or natural products)Do you have any known allergies to medication or food (In particular: bee sting, wine or milk?)Have you ever been hospitalized for a serious allergic reaction?Do you smoke? If so, how many cigarette(s) a day?Do you drink alcoholic beverages? If so, what is the frequency?Have you taken Aspirin, Advil or any other anticoagulants in the last ten days?Do you bruise easily? If so, please explainDo you have oral herpes (cold sores)?Have you ever received a Botox injection? If so, how long ago?Have you ever received a filler? If so, what product and how long ago?Did you have any side effects or allergic reaction to the injections?Have you ever had laser treatments or any kind of surgery (including eye surgery)?Have you ever had any eye problems? Eye or eyelid surgery?Do you have any problems with your sinuses? If so, please specify:Have you recently had or will you receive any dental treatment in the near future (2-3 weeks before or after this visit)?Have you ever had a problem with a local anesthetic? Please explainDo you have a chronic illness or any of the following diseases Have you had breast cancer?Are you pregnant or breastfeeding?Do you have any concerns or preoccupation in receiving any kind of treatment or is there anything else you wish to confide?

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