YOUR NAME:
PHONE NUMBER:
EMAIL:
INTERESTED PROCEDURE:



Like us on Facebook
Follow our Tweets
LinkedIn
RSS Subscription

Send Us Your Medical History

New Patient Submition Form:

I am interested in the following procedures:

Are you interested in our Skin Care Program?

Please provide the following contact information:

First Name:     M.I.:   Last Name:  
Organization:  
Street
Address: 		  Address (cont.):
City:   State/
 Province:		   Zip/Postal Code:
Cell Phone:   Home Phone:
Other Phone:   E-mail:
 
Are there any restrictions on contacting you at the above phone numbers?
If so, please list:   

Please identify and describe yourself:

SSN:   Married ?    Married to:  
Age  Date of Birth:  
Sex  
Height: Weight:

Patient's Employer:

Company
Name:   		  Occupation
Work Phone:   Ext:   Is it OK
 to call at work?
Street
Address: 		  Suite Number:
City:   State/
 Province:		   Zip/Postal Code:

Emergency Contact:

Name:     Relationship:
Work Phone:     Home Phone: 
Other Phone:

Primary Health Insurance Company:

Insurance Company Name:
Policy #:     Group #:   Ins. Phone:
Referral
 Required? 		Copay?
        $,
Insured: Name   DOB   Employer:

Secondary Health Insurance Company:

Secondary Insurance Company Name:  
Policy #:     Group #:   Ins. Phone:
Referral
 Required? 		Copay?
        $,
Insured: Name   DOB   Employer:

Please let us know who referred you.

if Friend, Patient or Other:

 

Dr. Nikko provides consultations for cosmetic procedures. I fully understand that I am financially responsible for all medical services to me at the time of services.

   Enter Initials:    

 

Are you allergic to any medications?


If so, please list:

Are you currently taking any medication?


If so, please list:

Personal History

How often do you drink alcohol?
Do you currently smoke?
If so, how often?

Pregnancies:
Date of last Period:

Have you been diagnosed with an anxiety or depression disorder in which you have received treatment or taken medication?

Have you ever been diagnosed with cancer?
Do you have family history of breast cancer?
Have you ever been diagnosed with:
              Hepititis A, B, and/or C?
              History of exposure to HIV?
              Have you had cosmetic surgery before?
              If yes, please list procedure and date.