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? 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

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:

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

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:

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.

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: