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

Height: ______Height________ Weight: ____Weight____

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: singleSingle marriedMarried ​​ 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 injectables like Botox and Juvederm? 

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

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_option Heart check_optionProblems 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 mediation? (Ozempic, ​​ Semaglutide, Mounjaro, ctc. ) 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
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