Welcome to our practice!     Today’s Date: Date

Please print legibly and fill in all fields.

Patient Name: __First_name_________Middle_initial______Last_name
First     M.I.    Last

Birthday: __ DOB_ ​​ SSN: _SSN ​​ __ ​​ Gender: copFemale copMale

Age: __ Age_ ​​ 

Street Address: street_address___
City/State/Zip: city_state_zip_____

Primary Phone: Primary-Phone___  ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​​​ 

Secondary Phone: Secondary_Phone__

Email: Email_________________ Preferred Contact Method:opPhone opEmail

Marital Status: single Single married Married Ethnicity: _____Ethnicity
Emergency Contact: Emergency_contact____ ​​ Phone: _Phone

Patient Employer: _____Patient-Employer__ Occupation: ____Occuption

We like to say thank you for referrals! Please share with us how you heard about Dr. Mazaheri?

copTV Ad copMagazine copNewsletter cop Seminar copSalon Salon_________________
copWebsite copDoctor _ Doctor_ref 

copFriend/Relative ___ friend_ref
copOther _____other_ref

We encourage you to select any/all goals you have, even if unrelated to your consultation. This will allow Dr. Mazaheri to address all concerns with you and see how we can help you achieve a more confident, radiant self.

Patient Goals:

What are your goals today? fill_in_goals_here

Learn more about medical grade skincare products? 

copYes copNo

Learn more about how custom facials can improve your skin’s feel and appearance? copYescopNo

Learn more about injectables like Botox and Juvederm? 

copYes copNo

Learn more about Viveve, a one-time vaginal restoration treatment? copYes copNo

Learn more about our med spa membership? copYes copNo

Patient Signature: Signature_________________ ​​ Date:__Date

*Have patient confirm information is correct one year from date above and sign below. *
Signature: Signature_________________________________ Date: Date

Health History

 ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​​​        Today’s Date: Date

Patient Name: __First_name___Middle_initials_____Last_name
  First    M.I.  Last

Birthday: __DOB__ Gender: cop Female copMale

​​ Age: __ Age_ ​​ 

Height: ______Height________ Weight: ____Weight____ ​​ 

Purpose for Today’s Visit:

Fill_In_today_visit

All Previous Surgeries (include year):
Fill_In_previous_surgeries

Health Problems (Past & Present):

check_optionDiabetes check_optionHigh Blood Pressure 

check_optionHeart Problems  ​​​​ check_optionLung/Breathing Problems
check_optionEasy Bruising check_optionBleeding/Clotting Problems

check_optionCancer check_optionPsychiatric/Depression
check_optionUrinary Symptoms/Leakage check_optionVaginal Dryness
check_optionOther: __check_option_text_

Please provide more information on positive responses: Fill_In_positive_response

Do you smoke? copYes copNo 

*If yes, how many packs per day? __number_of_packs

*Are you currently on any weight loss medication? (Ozempic, Semaglutide, Mounjaro, etc.): copYes copNo

Please list all current medications (include over-the-counter, supplements, and vitamins): Fill_in_meds______________

List all allergies: Fill_In_List_of_Allergies

Allergy to Latex? copYes  copNo

Primary Care Doctor: Primary_care_doctor____ Date of Last Physical:DLP

Patient Signature: Signature______________Date: Date

*Have patient confirm information is correct one year from date above and sign below. *
Signature: Signature______________________________ ​​ Date: Date