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

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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