Patient Registration Form | Tucson, Az | Taki Plastic Surgery
(520) 881-3232

Patient Registration Form

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Name (required)

Birthday (required)

Cell Phone Number

Email

Address (required)


Occupation

Employed By

Employer's Address

Business Phone


Nearest Friend or Relative

Relationship to Patient

Phone


Reason for Consultation (required)

Referred By


Height (required)

Weight (required)

Marital Status

Do you smoke? (required)
YesNo

If yes, how much do you smoke? (e.g. three cigarettes per day, a pack per day, etc.)

Are you allergic to any medication? (required)
YesNo

If yes, please explain.

Do you have any seasonal allergies? (required)
YesNo

Are you allergic to any foods or other substances? (required)
YesNo

Are you allergic to LATEX? (required)
YesNo

Are you currently taking any medications? (required)
Including birth control pills, diuretics (water pills), blood pressure or heart medications,
or ASPIRIN IBUPROFEN (ADVIL), NAPROXEN (ALLEVE), tranquilizers, hormones, steroid medications, cortisone, and/or blood thinners. * Please include implanted devices here (IUD or Pacemaker)

YesNo

If yes, please list all medications you are currently taking.

Have you ever had a REACTION to a GENERAL anesthetic? (Being put to sleep) (required)
YesNo

Have you ever had a REACTION to a LOCAL anesthetic? (Example: Novocain) (required)
YesNo

Have you ever had a problem with your heart? (required)
YesNo

Do you have high blood pressure? (required)
YesNo

Do you have fast or irregular heartbeats? (required)
YesNo

Do you have dizziness or fainting spells? (required)
YesNo

Have you ever had a problem with your lungs? (required)
YesNo

Asthma or Emphysema? (required)
YesNo

Sleep Apnea? (required)
YesNo

CPAP Machine? (required)
YesNo

Do you have stomach acid problems like Acid Reflux GERD/Heartburn? (required)
YesNo

Do you take acid reflux medication or use antacids? (Please list above) (required)
YesNo

Have you ever had any excessive bleeding problems? (required)
YesNo

Have you ever been diagnosed with or treated for blood clots? (required)
YesNo

Do you have diabetes? (required)
YesNo

Have you ever had a seizure? (required)
YesNo

Have you ever had psychiatric care? (required)
YesNo

Have you ever had a stroke, paralysis, vision loss, meningitis or polio? (required)
YesNo

Do you form heavy scars? (required)
YesNo

Do you have a personal or family history of breast cancer? (required)
YesNo

Have you ever been pregnant? (required)
YesNo

How may children do you have? (required)

Could you be pregnant now? (required)
YesNo

Have you seen other plastic surgeons about the SAME problem which brings you here? (required)
YesNo


Previous Surgeries

Please list any surgeries in your past.

Operation

Year

Were there any complications? If yes, please explain.


Operation

Year

Were there any complications? If yes, please explain.


Acknowledgement of Reciept of Privacy Health Information Practices

I have been presented with a copy of RAAD M. TAKI, M.D., P.C. Notice of Privacy Health Information Practices detailing how my information maybe used and disclosed as permitted under federal and state law. I understand the contents of the Notice, and I request the following restriction(s) concerning the use of my personal medical information:
Further, I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to the party who accepts assignment. Regulations pertaining to medical assignment of benefits apply.

Is all the information provided on this form correct to the best of your knowledge? (required)
YesNo

Date (required)

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