Surveypoint

Q1

Name

First Name

Q2

Name

Last Name

Q3

Date of Birth

Date

Q4

Gender

Q5

Phone Number

Q6

Email

Q7

Address

Street Address

Q8

Address

Street Address Line 2

Q9

Address

City

Q10

Address

State / Province

Q11

Address

Postal / Zip Code

Q12

Emergency Contact Person

First Name

Q13

Emergency Contact Person

Last Name

Q14

Emergency Contact Person Phone

Q15

Relationship

Q16

What procedure or service you're going to get?

Q17

Height

Q18

Weight

Q19

Blood Pressure

Q20

Heart Rate

Q21

Respiratory Rate

Q22

Are you pregnant or breastfeeding?

Yes

No

Q23

Are you smoking?

Yes

No

Q24

Are you drinking alcohol?

Yes

No

Q25

Are you under any medication for the last 6 months? If yes, please indicate and explain it below:

Q26

Are you taking any of the following medications?

Q27

Do you have any known allergies to food, cosmetics and drugs and medicine? If yes, please indicate and explain it below:

Q28

Do you have any medical conditions that the clinic should be aware of? If yes, please indicate and explain it below:

Q29

Do you have any of the following condition?

Q30

Do you have symptoms of COVID-19 for the past 7 days?

Yes

No

Q31

Were you exposed to someone with COVID-19 for the past 14 days?

Yes

No

Q32

Have you been vaccinated for COVID-19?

Yes

No

Q33

How did you hear about us?

Q34

Patient Signature

Q35

Date Signed

Date

Plastic Surgery Intake -Form Fill

Name

Name

Date of Birth

Gender

Phone Number

Email

Address

Address

Address

Address

Address

Emergency Contact Person

Emergency Contact Person

Emergency Contact Person Phone

Relationship

What procedure or service you're going to get?

Height

Weight

Blood Pressure

Heart Rate

Respiratory Rate

Are you pregnant or breastfeeding?

Are you smoking?

Are you drinking alcohol?

Are you under any medication for the last 6 months? If yes, please indicate and explain it below:

Are you taking any of the following medications?

Do you have any known allergies to food, cosmetics and drugs and medicine? If yes, please indicate and explain it below:

Do you have any medical conditions that the clinic should be aware of? If yes, please indicate and explain it below:

Do you have any of the following condition?

Do you have symptoms of COVID-19 for the past 7 days?

Were you exposed to someone with COVID-19 for the past 14 days?

Have you been vaccinated for COVID-19?

How did you hear about us?

Patient Signature

Date Signed