THE AESTHETIC SURGERY CENTER

The Aesthetic Surgery Center ™ Date: Name: 1.) How did you hear about The Aesthetic Surgery Center ™, The Face Spa™, Dr. Richard Maloney, and/or Dr. Anurag Agarwal? (select all that apply) Attended a Seminar Word of Mouth Positive Aging Television Show Take A Look Television Show Visted aestheticsurgerycenter.com Referral by a freind Other - Please specifiy 2.) Have you seen any of our advertisements? (select all that apply) N Magazine Gulfshore Life Naples Yellow Page Directory Naples Daily News Ft. Myers News Press Ft. Myers Yellow Page Directory 3.) What reason(s) were most important in your decision to make an appointment? (select all that apply) Dr. Maloney`s/ Dr. Agarwal`s extensive experience and credentials The location of The Aesthetic Surgery Center Skin care services offered Skin care products offered Computer Imaging System Office staff was knowledgeable and courteous Pricing seemed fair and reasonable Referral from someone else Thank you for taking the time to complete our questionnaire RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com Welcome to Our Office PLEASE PRINT The Aesthetic Surgery Center ™ Date Last Name Address First Name City Middle State Zip Code Email Address OUT OF TOWN ADDRESS: Address City State Zip Phone Number How did you hear about Dr. Maloney or Dr. Agarwal? Did you attend one of our Seminars? YES NO Female Social Security # (last 4) Date of Birth Height Weight Age Sex Male Martial Status (check one) Home Phone Cell Phone SING MAR WID DIV SEP Employer Spouse`s Name Primary Insurance Company Policy Holder Next of Kin Employer`s Address Occupation Secondary Insurance Company Policy Holder`s Date of Birth Relation to the Patient Business Phone Business Phone Policy Holder`s SSN Phone Number Which surgical procedures are you interested in? (check all that apply) Forehead/Brow Lift Eye Lid Procedure Skincare Botox Other Mid-Face Lift Chemical Peel Lip Enhancement Facial Fillers Lower Face/Neck Lift Laser Wash Rhinoplasty Hair Restoration RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com The Aesthetic Surgery Center ™ We request that ALL FEES FOR OFFICE TREATMENT OR CONSULTATION BE PAID AT THE TIME OF VISIT. 1. WHAT IS THE PURPOSE OF THIS CONSULTATION? (Please specify) 2. HAVE YOU SPECIFIC INSTRUCTIONS FOR CONFIDENTIALLY IF WE NEEDTO CONTACT YOU? 3. HAVE YOU EVER CONSULTED A PLASTIC SURGEON? (Please give details) 4. HAVE YOU EVER HAD ANY PLASTIC SURGERY? (Please describe & include dates) 5. WERE YOU SATISFIED WITH THE RESULTS OF ANY PLASTIC SURGERY YOU MAY HAVE HAD? 6. HAVE YOU OR AN IMMEDIATE FAMILY MEMBER EVER OR ARE PRESENTLY INVOLVED IN LITIGATION AGAINST A PHYSICIAN OR HEALTH CARE PROVIDER? YES NO 7. LAST GENERAL PHYSICIAN EXAM Date Physician Doctor`s # 8. PLEASE LIST ANY SURGERIES YOU MAY HAVE HAD: TYPE DATE SURGEON COMPLICATIONS RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com The Aesthetic Surgery Center ™ 9. PLEASE LIST ANY OTHER HOSPITALIZATIONS: TYPE DATE PHYSICIAN COMPLICATIONS 10. DO YOU HAVE, OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING? (check all that apply) Heart Disease Lung Disease Kidney Disease Liver Disease Thyroid Disease Diabetes High Blood Pressure Hepatitis Cancer Stroke Headache Glaucoma Epilepsy Alcoholism Anemia Sickle Cell Disease Recent Infection HIV Stomach Ulcers Problems with scars Bruise / Bleed easy Immune Deficiency Cold Sores Problems with Anesthesia Mitral Valve Prolapse Currently Pregnant AIDS Do you have any other medical conditions not noted above? (Please explain) 11. HAVE YOU EVER RECEIVED TREATMENT FOR A MENTAL CONDITION, EMOTIONAL PROBLEM OR DEPRESSION? YES NO (if yes, please explain below) 12. DO YOU, OR HAVE YOU, EVER USED ANY DRUGS FOR RECREATIONAL PURPOSES? THE FOLLOWING MAY INTERACT WITH SOME ANESTHETICS: Marijuana LSD / ACID Cocaine / Crack Heroin Other 13. WHAT MEDICATIONS ARE YOU CURRENTLY TAKING? (Please do not omit anything because medications used during and after surgery may interact adversely.) MEDICATION DOSAGE FREQUENCY PURPOSE RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com The Aesthetic Surgery Center ™ 14. HAVE YOU EVER HAD A BAD REACTION OR ALLERGIC REACTION TO ANY OF THE FOLLOWING? (If you answer yes to any, please explain in detail) Penicillin Other Antibotics Morphine / Codeine Demerol / Other Narcotics Novocaine / Xylocaine Other Anesthetics Aspirin / Empirin Other Pain Remedies Tetanus / Other Serums Adhesive Tape Lodine Merthiolate PhisoHex / Hibiclens Other Antiseptics Latex Any food Allergeries Any Inhalant Allergies Other 15. DO YOU CURRENTLY SMOKE? YES NO DID YOU EVER SMOKE? YES NO If yes, when did you quit? IF YES TO EITHER QUESTION, PLEASE ANSWER How many years? Number of packs per day? 16. IS THERE A CHANCE THAT YOU MAY BE PREGNANT OR BECOME PREGNANT WITHIN THE NEXT 6 MONTHS? YES NO NA (if yes, please explain below) ... - tailieumienphi.vn