Schilling Healthcare Intake Forms · PDF file Enhancement & Abdominoplasty (tummy tuck)...

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Transcript of Schilling Healthcare Intake Forms · PDF file Enhancement & Abdominoplasty (tummy tuck)...

  • Welcome

    Cosmetic Surgery Center Medical Spa 770.506.9123 www.SchillingMedicalSpa.com

    Women’s Center 770.474.7151 www.SchillingWomensCenter.com

    290 Country Club Drive Suite 110 and Suite 130 Stockbridge, GA 30281

    John P. Schilling, MD, FACOG

    If you upgrade to most recent Acrobat Reader, then you’ll be able to see this file as it was designed, as a PDF Portfolio. This upgrade is FREE. Click this link to upgrade: http://get.adobe.com/reader/ .

    However, the files contained in this PDF are exactly the same regardless of which version of Reader or Acrobat you’re using.

    Please feel free to contact us if you need assistance.

    Please choose appropriate intake form:

    ➡ Schilling Medical Spa CLIENT Intake (Aesthetic & Laser Services)

    ➡ Cosmetic Surgery Intake ( Breast Augmentation, Liposuction, Fat Grafting / Enhancement & Abdominoplasty (tummy tuck)

    ➡ Weight-loss ONLY Intake Form

    Fill out all information completely.

    When you finish - choose from below how you would like to send information

    ! by mail: ! Schilling Medical Spa ! 290 Country Club Drive, Ste 110 ! Stockbridge, GA 30281 ! or choose: !PRINT and bring to appointment.

    or choose:! EMAIL and we will print and have your information ready for your upcoming appointment!

    Schilling Heatlhcare talktous@schillingmedicalspa.com

    a practice by

    John P. Schilling, MD, FACOG..

    Women’s Center. Cosmetic Surgery Center. Anti-Aging Medical Spa.

    http://www.adobe.com/go/reader

  • If you upgrade to most recent Acrobat Reader, then you’ll be able to see this file as it was designed, as a PDF Portfolio. This upgrade is FREE. Click this link to upgrade: http://get.adobe.com/reader/ .

    However, the files contained in this PDF are exactly the same regardless of which version of Reader or Acrobat you’re using.

    Please feel free to contact us if you need assistance.

    Please choose appropriate intake form:

    Medical Aesthetic DATA Form (Aesthetic & Laser Services)

    Cosmetic Surgery Consult DATA Form ( Breast Augmentation, Liposuction, Fat Grafting / Enhancement & Abdominoplasty (tummy tuck)

    Medical WEIGHT-LOSS Data Form (Weight-Loss ONLY)

    Fill out all information completely.

    When you finish - choose from below how you would like us to receive your informa- tion.

    by mail: Schilling Healthcare 1757 Rock Quarry Road Stockbridge, GA 30281

    or choose: PRINT and bring to appointment.

    or choose: EMAIL and we will print and have your information ready for your upcoming appointment!

    We look forward to meeting you! Schilling Heatlhcare

    a practice by John P. Schilling, MD

    Obstetrics Gynecology Cosmetic Surgery Medical Aesthetics  

    1757 Rock Quarry Road Stockbridge, GA 30281

    Women’s Center (770) 474-7151 Weight-Loss (770) 474-7151 Cosmetic Surgery Center (770) 506-9123 Medical Aesthetics (770) 506-9123

    Address:

    Phone:

    John P. Schilling, MD, FACOG Tamika L. Sea, MD

    Website: SchillingMedicalSpa.com SchillingWomensCenter.com

    Email: talktous@schillingmedicalspa.com

    Social Media: facebook.com/johnschillingmd @drjohnschilling

    Online Newsletter: issuu.com/schillinghealthcare

  • Patient Name: Address:

    Mailing Address (if different): Home: Cell: Work: Email Address: How did you hear about us?

    Medical Aesthetic Data Form

    1757 Rock Quarry Road Stockbridge, GA 30281

    T (770) 506-9123 F (770) 506-1915

    SchillingMedicalSpa.com

    Patient ID: (FOR OFFICE USE) Today’s Date:

    DOB: Social Security #:

    EMERGENCY CONTACT Name: EMERGENCY CONTACT Phone: Relationship:

    Employer: Occupation:

    If a friend, name?

    check preferred contact number

    a practice by John P. Schilling, MD

    Obstetrics Gynecology Cosmetic Surgery Medical Aesthetics

    Facials - Facial Services Chemical Peels Home Skin Care Products Hyper-Pigmentation Rosacea

    Microdermabrasion Botox® Dysport® Juvéderm® Radiesse® Sculptra® Laser Stretchmark Reduction Laser Skin Tightening/Anti-Aging

    Please tell us what you would like more information about: Laser Hair Reduction Laser Vein Treatment Weight-Loss Smartlipo® & Liposuction Lipo-Abdominoplasty (Tummy Tuck)

    Facial Fat Grafting Buttocks Enhancement Breast Augmentation

    m ed

    Ic aL

    h IS

    to rY

    Breast-feeding Arthritis Anemia Asthma Blood Pressure

    Cancer Chronic Pain Diabetes Depression Edema

    Epilepsy Fatigue Fibromyalgia Heart Disease HIV / Aids

    Insomnia Numbness Sinus Problems Smoker Spinal Problems Varicose Veins

    Please check all that apply:

    List ANY operation, surgery, or serious illness that have required hospitalization: Month/ Year Operation or Illness Complications (any)?

    Have you ever had a cold sore or fever blister? NO YES Are you sensitive to LATEX? NO YES Are you currently pregnant? NO YES Are you attempting pregnancy? NO YES Do you wear contacts or eyeglasses? NO YES, Specify: ARE YOU CURRENTLY USING ANY ORAL MEDICATIONS? NO YES, Specify: ARE YOU CURRENTLY USING ANY TOPICAL MEDICATIONS? NO YES, Specify: Do you use birth control pills? NO YES, Specify: Do you have any allergies? NO YES, Specify:

  • Sk In

    c ar

    e pr

    of IL

    e

    Have you ever taken Accutane? NO Yes, When Dosage Amt of time Have you used Tretinoin (Retin-A)? NO Yes, Dosage (%)

    Have you ever had any of the following procedures? Please give dates and any important details.

    Botox/Dysport Restylane/Radiesse/Other filler? Sculptra Comedone (blackheads) Extraction

    Laser Chemical Peels Facial Surgeries Number of Facials in last 12 months

    Even color Tone Skin Pigmentation Acne Skin Hydration

    Lines / Wrinkles Skin Elasticity Skin texture Acne Scars

    Skin Disorder (list) Other Areas of Concern: Current skin care products used:

    Areas of Concern (Please check all that apply):

    La Se

    r ha

    Ir r

    ed uc

    tI on

    & W

    aX In

    G

    Please list any previous LASER or LIGHT-BASED hair reduction/removal treaments you have received:

    Area(s) Treated Dates of Treatment Results/Comments (any sensitivity?)Type of Device Used

    Other Hair Removal History:

    Are you currently using any of the following tanning methods? (If so, please list last date used.)

    Waxing: Tweezing: Electrolysis: Bleaching: Shaving: Other:

    How often? Last time (date): List complications or sensitivity (if any):

    Tanning Beds Outdoor Tanning

    Airbrush Tanning Sunless Tan Lotions

    Last time (date): Last time (date):

    co nS

    en t a

    nd S

    IG na

    tu re

    I have listed all known medical/physical conditions, if there are any changes in the future, I will inform my PROVIDER at Schilling Healthcare Ent., PC of any changes. I agree to pay for all services at time they are rendered.

    I understand that when scheduling an appointment I am required to reserve the appointment with a Credit Card or Gift Card number and a 24 hour notice is required to avoid paying missed appointment fees. A $30 fee will be charged for all returned checks.

    I acknowledge by my signature below that I have read and understand the above statements and give my permission to receive this and any further treat- ments at Schilling Healthcare Ent., PC. I confirm to the best of my knowledge that the answers I have given on both pages, are correct and, that I have not withheld any information that may be relevant to my treatment.

    Signature Date today (please add additional date if information is updated)

    offIce uSe onLY: Date ENTERED: Initials: Date UPDATED: Initials: Date UPDATED: Initials: Date UPDATED: Initials:

    Important Information for: Microdermabrasion, Facials, Chemical Peels, Injectables, Waxing, Laser or Light-Based Treatments

  • a practice by John P. Schilling, MD

    Obstetrics Gynecology Cosmetic Surgery Medical Aesthetics  

    We would like to sincerely thank you for choosing our practice. Our goal is to de- velop a trusting relationship with you and provide excellent care and services to keep you healthy. We even offer some extra services to keep you looking as good as you feel.

    Our doctors are dedicated to keep up with the latest training, techniques and prac- tices on complex female health issues. You can feel confident they will listen to you and understand your personal needs.

    Our practice is unique because we offer obstetrical and gynecological services, medi- cal aesthetic services, and cosmetic surgery.

    Now that you have your appointment scheduled, we just wanted to let you know the other services we offer and would love for you to join us on social media to stay con- nected, hear the latest news, and even get special offers! Also, check out our quar- terly newsletters full of fun and informative information.

    Facials - Facial Services Chemical Peels Home Skin Care Pro