BOSTON COSMETIC SPECIALISTS
www.BostonCosmeticSpecialists.com
info@Bostonacs.com

CLIENT QUESTIONNAIRE & MEDICAL HISTORY FORM

Emergency Contact Information:

Cosmetic Procedure Goals:

Cosmetic Procedure History:

Please tell us about any previous cosmetic procedures or cosmetic surgeries you’ve had:

If not, why were you unsatisfied?

General Medical History & Evaluation:

Do you... Drink more than six (6) cups of coffee or tea daily? Yes No 

Drink alcoholic beverages? Yes No  If yes, how many per week?

Smoke? Yes No  If yes, how much?

Use marijuana? Yes No  If yes, how much?

Use recreational drugs such as cocaine, speed, LSD or heroin? Yes No  If yes, which drug(s)?

Have any hobbies? Yes No 

Spend much time socializing with friends and family? Yes No 

Tend to wrap yourself up in your work or school, to almost total exclusion of other aspects of life? Yes No 

Find that you are unhappy most of the time? Yes No 

Feel lonely a great deal of the time? Yes No 

Has your weight changed by more than five (5) lbs. in the last year? Yes No 

How often do you exercise per week? What kind of exercise do you practice?

When was your last physical exam? What kind of exercise do you practice? At the physical, was everything OK? Yes No 

Family Physician’s Name: Physician’s Phone #:

List any previous surgeries or procedures not covered earlier:

If you have had surgery before, did you have any unusual bleeding or poor scarring following surgery? Yes No 

Did you have a normal recovery following previous surgery? Yes No  If not, explain:

Have you ever had a hemorrhage following a minor procedure or surgery? Yes No 

Do you, or have you ever, suffered from recurrent nosebleeds? Yes No 

List any current medical conditions:

List any other medical facts or information you feel should be known by our doctor before you undergo any type of procedure:

(use the backside of this form if additional space is required for this or other questions)

For Female Clients:

Medical History Questions:

1. Have you had a heart attack or stroke within the last twelve (12) months? Yes No 

2. Are you currently taking steroids or any other immunosuppressant medication? Yes No 

3. Are you currently pregnant or breastfeeding? Yes No 

4. Are you currently undergoing radiation or chemotherapy for cancer? Yes No 

5. Do you have a history of skin disease or connective tissue disorder? Yes No 

6. Do you have severe emphysema or other oxygen dependent condition? Yes No 

7. Are you currently taking Coumadin, Plavix, Aspirin, Ibuprofen, or any other blood thinners on doctor’s orders? Yes No 

8. History of a bleeding disorder or excessive bleeding? Yes No 

9. Do you have a history of keloids or abnormal scarring? Yes No 

10. Are you allergic to latex? Yes No 

11. Do you have a progressive neurologic illness (current paralysis, multiple sclerosis, Parkinson’s)? Yes No 

12. Do you have a history of hyper- or hypo-pigmentation after skin injury? Yes No 

13. Do you have a pacemaker? Yes No 

14. Angioplasty with a stent placement? Yes No 

16. High blood pressure? Yes No 

17. Mitral valve prolapse? Yes No 

18. Limited spine mobility? Yes No 

19. Restless leg syndrome? Yes No 

20. History of abdominal surgery or C-section? Yes No 

21. Poor wound healing? Yes No 

22. Psychiatric disease that required hospitalization? Yes No 

23. Reaction to Lidocaine? Yes No 

24. Angina or chest pain with exercise? Yes No 

25. Do you bruise easily? Yes No 

26. Coronary artery disease or history of heart attacks? Yes No 

27. Diabetes that cannot be controlled with diet? Yes No 

28. Hepatitis B or C? Yes No 

29. Tuberculosis? Yes No 

30. Sickle cell anemia or trait? Yes No 

31. History of aortic aneurysm? Yes No 

32. History of hernia (ventral, umbilical or inguinal)? Yes No 

33. History of stroke? Yes No 

34. HIV/AIDS? Yes No 

35. Irregular heart beat (arrhythmia)? Yes No 

36. History of kidney insufficiency or failure? Yes No 

37. Liver insufficiency or Cirrhosis? Yes No 

38. Phlebitis, blood clot or deep vein thrombosis (DVT)? Yes No 

Acne History Questions:

40. Have you ever been on Retin-A for acne? Yes No 

41. Have you ever taken Accutane for acne? If yes, start date: End date Yes No 

42. Have you ever been on antibiotics for acne? If yes, when did you stop? Yes No 

43. Rate your current skin condition. Is it the same, better, or worse than usual? Better Same Worse 

44. What current medications are you taking for acne?

45. For women with acne: Have you noticed a change connected to your menstrual cycle? Yes No 

I acknowledge that I have disclosed my complete medical history and the above is complete and accurate to my knowledge of my medical and psychological status. I am at least 18 years of age or, if not, I am accompanied by a legal guardian. I hereby consent to and authorize that Boston Cosmetic Surgery Center staff take a medical history in order to evaluate, plan, and help educate me on the possibilities of procedures I can be offered. I understand that photos are helpful and I authorize the taking of photos, which will be used solely for documentation and be kept confidential. I agree that any critical omission or misrepresentation may lead to change in pricing or cancellation.

ACKNOWLEDGEMENTS

1. Client covenants and agrees that he/she shall not, in his/her own name, pseudonymously, or anonymously, hereafter engage in conduct that involves the making or publishing of written or oral statements or remarks (including, without limitation, the repetition or distribution of derogatory rumors, allegations, negative reports or comments) orally, on paper, electronically, or through any other medium, which are disparaging, deleterious or damaging to the integrity, reputation or good will of Dr. Ishoo, Dr. Davison and or Boston Cosmetic Specialists.

2. I understand that I will require an adult escort to accompany me home following the operation as a matter of client safety because I will have received medications during the procedure. I also understand that I am strictly prohibited from operating a motor vehicle immediately after the operation and for as long as I am taking narcotics or sedatives, which can impair my judgment and motor skills putting myself and others at risk for injury. I understand that if I do not have an escort my procedure will be rescheduled at my expense to a date where one can be made available.

3. We value our clients’ privacy and in order to protect your privacy, it is the policy of this office to prohibit the use of sound, video and other electronic recording devices, including cell phone cameras. The use of such devices is a violation of the right to privacy of both our clients and employees. By signing below, client agrees that such conduct is an invasion of the privacy of others and will refrain from using recording devices on Boston Cosmetic Specialists premises.

4. For female clients: I acknowledge that I am NOT pregnant NOR breastfeeding at this time. I understand that if I become pregnant or suspect that I am pregnant I must notify the doctor and his staff prior to any procedure involving medications

BOSTON COSMETIC SPECIALISTS POLICIES

Appointment Policy:

• We require a credit card number to reserve your appointment. Please give us at least forty-eight (48) hours notice for appointment cancellations or to reschedule an appointment. If you cancel or reschedule your appointment with less than forty-eight (48) hours notice, or fail to come to your appointment, a $50 cancellation charge will be applied to your credit card
• Our quotes and deposits are valid for fourteen (14) days.

Payment Policy:

• We require a credit card number to reserve your appointment. Please give us at least forty-eight (48) hours notice for appointment cancellations or to reschedule an appointment. If you cancel or reschedule your appointment with less than forty-eight (48) hours notice, or fail to come to your appointment, a $50 cancellation charge will be applied to your credit card
• Our quotes and deposits are valid for fourteen (14) days.

Refund Policy:

• Boston Cosmetic Specialists will not issue refunds for services purchased or rendered. We may, at our sole discretion, issue a full or partial credit for use at our facility towards other services. This credit may not be transferable.
• We are committed to setting up realistic expectations. All clients must recognize that results vary based on a variety of factors, so there is no guarantee of specific results.
• If returned unopened or unused, our products may be exchangeable for other products, facility credit, or monetary refund. Exchanges, credit, and refunds are at the sole discretion of Boston Cosmetic Specialists.

Procedure Change or Cancellation:

• By scheduling and paying a one-third (1/3) and/or full payment for your procedure, You are confirmed for your procedure on the date you have selected. If you need to change or cancel your procedure within two weeks prior to your procedure, a nonrefundable fee of twenty percent (20%) of the surgical fee or $500 (whichever is greater) will be ducted from your account with us.

Procedure Change or Cancellation: