________________________________________________________________________________________________

________________________________________________________________________________________________ REASON FOR VISIT
DATE OF VISIT

_______________
________________________________________ MR/MRS/MISS
PREFERRED FIRST NAME
HOME PHONE
_______________________________ ________________________ FIRST NAME
MIDDLE NAME
LAST NAME
WORK PHONE

________________________________________________________________________________ _______ (__________)_____________________
ADDRESS
MOBILE PHONE

________________________________________________________
FEMALE
SOCIAL SECURITY NUMBER
SINGLE
MARRIED
OTHER
BIRTH DATE
___________________________________________________________ ________________________________________________________ SPOUSE’S NAME
E-MAIL ADDRESS
EMERGENCY CONTACT
_______________________
___________________________________
MAY WE LEAVE A MESSAGE FOR YOU AT HOME? YES NO FIRST NAME
LAST NAME
MAY WE EMAIL TO THE ADDRESS PROVIDED? YES NO ___________________________________________________________ RELATIONSHIP
HOME PHONE
INSURANCE INFORMATION
WORK PHONE
________________________________________________________ PRIMARY INSURANCE COMPANY NAME
MOBILE PHONE
________________________________________________________ EMPLOYMENT INFORMATION
NAME OF INSURED
________________________________________________________ INSURED’S ADDRESS IF DIFFERENT FROM ABOVE
___________________________________________________________ OCCUPATION
INSURED’S DATE OF BIRTH
INSURED’S SS #
___________________________________________________________ __________________________________________ COMPANY OR SCHOOL
INSURED’S RELATIONSHIP TO PATIENT
___________________________________________________________ (__________)___________________________________ MANAGER’S NAME
___________________________________________________________ _________________________________________________ POLICY NUMBER
__________________________________________________ GROUP NUMBER
910 Fifth Avenue New York, New York 10021 Tel: 212-400-0999 Fax: 212-400-0991 HOW DID YOU HEAR ABOUT DR. AIRAN?
PLEASE CHECK ALL THAT APPLY.
BRAND/NAME RECOGNITION
REFERRING DR.: ______________________
FRIEND OR RELATIVE: ______________________
MAGAZINE:
O MAGAZINE
WOMAN’S WEAR DAILY
OTHER MAGAZINE: _______________________________________
NEWSPAPER:
DAILY NEWS
OTHER_______________________
TELEVISION:
TYRA BANKS
OTHER TELEVISION: _______________________________________
WEBSITE:
DRLISAAIRAN.COM
BOTOXCOSMETIC.COM
OTHERWEBSITE: _______________________________________
PLEASE CHECK ALL THAT INTEREST YOU:
INJECTABLE FILLERS
PRODUCT OR SKIN CARE RECOMMENDATIONS
FACIAL PEEL FOR:
SKIN REJUVENATION
GENTLEWAVES
VIBRADERM
NON-SURGICAL LOWER EYELID LIFT/PERIORBITAL AUGMENTATION (POA)
THERMAGE SKIN TIGHTENING
SCLEROTHERAPY FOR LEG VEINS
LASER TREATMENTS FOR:
HAIR REMOVAL
SKIN REJUVENATION
BROWN SPOTS
SKIN RESURFACING
FACIAL OR LEG VEINS
TATTOO REMOVAL
FACIAL REDNESS/ROSACEA
_________________________________________________________________________________________________
910 Fifth Avenue New York, New York 10021 Tel: 212-400-0999 Fax: 212-400-0991 PATIENT HEALTH DISCLOSURE STATEMENT
Please answer all questions.
Date ____________

Name: ______________________________________
Are you under a doctor’s care? _____ yes _____ no If yes, for what condition? _________________________________ Illnesses (List any serious or chronic illness):
1. ________________________________________________ 2. __________________________________________________ 3. ________________________________________________ 4. __________________________________________________ 5. ________________________________________________ Operations (List all previous surgery):
1. ________________________________________________ 2. __________________________________________________ 3. ________________________________________________ 4. __________________________________________________ 5. ________________________________________________ Other: _______________________________________________ Do you have any of the following?
(Please Circle):
Important Medical Conditions: Have you ever had or received treatment for any of the following?
(Please circle)
Hepatitis, jaundice, cirrhosis, or liver disease? Asthma, TB, pneumonia, emphysema or chest disease? Heart attack, angina, palpitations or irregular heart beats? Rheumatic fever or congenital heart disease? High blood pressure or Low blood pressure? Kidney failure, kidney or prostate problems? Migraines, headaches or chronic head pain? Lupus, arthritis, or autoimmune disease? Nervous breakdown or personality disorder? Adverse or unusual reaction to anesthesia? Phlebitis, blood clots or varicose veins? Abnormal healing or poor scar formation? Stroke, seizures, Bell’s palsy or neurological problems? Shingles, cold sores, fever blisters or oral herpes? 910 Fifth Avenue New York, New York 10021 Tel: 212-400-0999 Fax: 212-400-0991 Drugs and Medicines: Have you, within the last 6 months, taken any of the following?
(If yes, please circle)
Stimulants, appetite suppressants, diet pills? Sedatives, tranquilizers, or sleeping pills? Antidepressants, antipsycotics or nerve pills? Medications that cause bleeding: Have you taken any of the following in the last 2 weeks?
(If yes, please circle)
Aspirin or aspirin containing medications? Ibuprofen, (Motrin, Advil, Nuprin) containing products? Anti-inflammatories or muscle relaxants? Allergies and Sensitivities: Is there any history of skin reaction or other illness following the administration of:
(If yes, please circle)
Penicillin, Sulfa, or other antibiotics? Novocaine, Lidocaine, or local anesthetics? Iodine, Betadine, Chlorhexidine, or Phisohex? Pregnancy:
I certify that the above is true and correct. I realize that withholding information about my medical history could result in serious injury to me or harm to those involved in my care. I am aware that providing either false or incomplete information about my medical and surgical history may result in the cancellation of my proposed surgical procedure and also result in forfeiture of my surgical fees. ____________________________________________ Patient’s signature
910 Fifth Avenue New York, New York 10021 Tel: 212-400-0999 Fax: 212-400-0991

Source: http://www.drlisaairan.com/downloads/patientregistrationforms.pdf