Boston Cosmetic
Boston Cosmetic

















Boston Cosmetic

Application Form



    First Name

    Last Name


    Home Address




    Home Phone #

    Mobile Phone #

    Work Phone #

    Email Address


    Best number for confirmation calls?

    Best way to contact you? At what times?

    Are you single, married, divorced or widowed?

    How did you learn about us?

    Emergency Contact Information:

    Emergency Contact Name:

    Emergency Contact Phone #:

    What is the relationship to you ?

    Can they pick up prescriptions for you ? YesNo

    Cosmetic Procedure Goals:

    Indicate the areas you are considering for a procedure:




    What is the primary reason for this consultation?

    What specific features of yourself do you dislike? why ?

    How long have you been considering a cosmetic procedure? Is this motivated by an event?

    Is the cosmetic procedure your idea, or is someone else urging you to have it?

    Do you understand that the object of any cosmetic procedure is improvement in appearance, not perfection?


    Do you realize that every operation is followed by a period of healing before tissues return to normal and the final result is apparent?


    Why did you select us for a consultation visit?

    Cosmetic Procedure History:

    Have you consulted any other physician about a cosmetic procedure?

    If yes, when?

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

    Were you satisfied with the results?

    Were you satisfied with the physician(s)?

    If not, why were you unsatisfied?

    General Medical History & Evaluation:

    Do you... Drink more than six (6) cups of coffee or tea daily? YesNo

    Drink alcoholic beverages? YesNo If yes, how many per week?

    Smoke? YesNo If yes, how much?

    Use marijuana? YesNo If yes, how much?

    Use recreational drugs such as cocaine, speed, LSD or heroin? YesNo If yes, which drug(s)?

    Have any hobbies? YesNo

    Spend much time socializing with friends and family? YesNo

    Tend to wrap yourself up in your work or school, to almost total exclusion of other aspects of life? YesNo

    Find that you are unhappy most of the time? YesNo

    Feel lonely a great deal of the time? YesNo

    List your current height :


    Gender: MaleFemale

    Age :

    Has your weight changed by more than five (5) lbs. in the last year? YesNo

    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? YesNo

    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? YesNo

    Did you have a normal recovery following previous surgery? YesNo If not, explain:

    Have you ever had a hemorrhage following a minor procedure or surgery? YesNo

    Do you, or have you ever, suffered from recurrent nosebleeds? YesNo

    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:

    Number of pregnancies:

    Did you breastfeed? YesNo

    Date of last period:

    Are your periods heavy? YesNo

    Medical History Questions:

    1. Have you had a heart attack or stroke within the last twelve (12) months? YesNo

    2. Are you currently taking steroids or any other immunosuppressant medication? YesNo

    3. Are you currently pregnant or breastfeeding? YesNo

    4. Are you currently undergoing radiation or chemotherapy for cancer? YesNo

    5. Do you have a history of skin disease or connective tissue disorder? YesNo

    6. Do you have severe emphysema or other oxygen dependent condition? YesNo

    7. Are you currently taking Coumadin, Plavix, Aspirin, Ibuprofen, or any other blood thinners on doctor’s orders? YesNo

    8. History of a bleeding disorder or excessive bleeding? YesNo

    9. Do you have a history of keloids or abnormal scarring? YesNo

    10. Are you allergic to latex? YesNo

    11. Do you have a progressive neurologic illness (current paralysis, multiple sclerosis, Parkinson’s)? YesNo

    12. Do you have a history of hyper- or hypo-pigmentation after skin injury? YesNo

    13. Do you have a pacemaker? YesNo

    14. Angioplasty with a stent placement? YesNo

    15. Heart catheterization / stress test? If yes, date

    Results YesNo

    16. High blood pressure? YesNo

    17. Mitral valve prolapse? YesNo

    18. Limited spine mobility? YesNo

    19. Restless leg syndrome? YesNo

    20. History of abdominal surgery or C-section? YesNo

    21. Poor wound healing? YesNo

    22. Psychiatric disease that required hospitalization? YesNo

    23. Reaction to Lidocaine? YesNo

    24. Angina or chest pain with exercise? YesNo

    25. Do you bruise easily? YesNo

    26. Coronary artery disease or history of heart attacks? YesNo

    27. Diabetes that cannot be controlled with diet? YesNo

    28. Hepatitis B or C? YesNo

    29. Tuberculosis? YesNo

    30. Sickle cell anemia or trait? YesNo

    31. History of aortic aneurysm? YesNo

    32. History of hernia (ventral, umbilical or inguinal)? YesNo

    33. History of stroke? YesNo

    34. HIV/AIDS? YesNo

    35. Irregular heart beat (arrhythmia)? YesNo

    36. History of kidney insufficiency or failure? YesNo

    37. Liver insufficiency or Cirrhosis? YesNo

    38. Phlebitis, blood clot or deep vein thrombosis (DVT)? YesNo

    Acne History Questions:

    39. Are you currently taking acne medication? If yes, which?


    40. Have you ever been on Retin-A for acne? YesNo

    41. Have you ever taken Accutane for acne? If yes, start date: End date YesNo

    42. Have you ever been on antibiotics for acne? If yes, when did you stop? YesNo

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

    44. What current medications are you taking for acne?

    45. For women with acne: Have you noticed a change connected to your menstrual cycle? YesNo

    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.

    Please review the above information for accuracy, which you hereby verify by signing below.


    Date :

    Relationship to client: SelfSpouseParentGuardian


    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.


    Date :

    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.


    Date :

    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.


    Date :

    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


    Date :


    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:

    Accepted and Agreed To:


    Date :