Download - Schilling Healthcare Intake Forms · Enhancement & Abdominoplasty (tummy tuck) Weight-loss ONLY Intake Form Fill out all information completely. When you ﬁnish - choose from below

Welcome

Cosmetic Surgery CenterMedical Spa770.506.9123www.SchillingMedicalSpa.com

Women’s Center770.474.7151www.SchillingWomensCenter.com

290 Country Club DriveSuite 110 and Suite 130Stockbridge, 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 [email protected]

a practice by

John P. Schilling, MD, FACOG..

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

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

Patient Name:Address:

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

Medical WEIGHT-LOSS Data Form

(If you become an obstetrical, gynecologic or cosmetic surgery patient - you MUST fill out complete history

form - this form is for weight-loss only.)

1757 Rock Quarry RoadStockbridge, GA 30281

T (770) 474-7151 F (770) 506-1915SchillingWomensCenter.com

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 preferredcontact number

Facials - Facial ServicesChemical PeelsHome Skin Care ProductsHyper-Pigmentation

RosaceaMicrodermabrasionBotox® Dysport®

Juvéderm® Radiesse® Sculptra®

Please tell us what you would like more information about:Laser Stretchmark ReductionLaser Skin Tightening/Anti-AgingLaser Hair ReductionLaser Vein Treatment

Smartlipo® & LiposuctionLipo-Abdominoplasty (Tummy Tuck)Facial Fat GraftingButtocks EnhancementBreast Augmentation

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Please check all that apply:

a practice by John P. Schilling, MD

John P. Schilling, MD, FACOGTamika L. Sea, MD

NO YES Has your current weight remained stable over the last 5 years? If NO, how much has it fluctuated?How many diets have you tried over the last 5 years? If yes, how many pounds did you lose?Have you previously taken over-the-counter or prescription weight loss drugs? If yes, specify:How many hours a week do you exercise?Do you drink alcohol? If yes, how much?Are you taking anti-depressant or anxiety medication? If yes, specify:List any medications you are presently taking:Do you have any drug allergies? If yes, specify:Have you or anyone in your family been diagnosed with thyroid problems? If yes, specify:Have you ever been diagnosed with Metabolic Syndrome? If yes, specify:Have you been diagnosed with poly-cystic ovarian syndrome (PCOS)? If yes, specify:Are you planning to be pregnant in the near future? If yes, specify:

DESIRED GOAL WEIGHT:

conS

ent a

nd S

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ture

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 treatments 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)

Breast-feedingArthritisAnemiaAsthma

Blood PressureCancerChronic PainDiabetes

DepressionEdemaEpilepsyFatigue

FibromyalgiaHeart DiseaseHIV / AidsInsomnia

NumbnessSinus ProblemsSmokerSpinal Problems

Varicose VeinsClotting Disorders

OFFICE USE ONLY: CURRENT WEIGHT: HEIGHT: ABDOMINAL GIRTH: BMI:


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 ServicesChemical PeelsHome Skin Care ProductsHyper-Pigmentation RosaceaMicrodermabrasionBotox® Dysport®


Laser Stretchmark Reduction

Laser Skin Tightening/Anti-AgingLaser Hair ReductionLaser Vein TreatmentWeight-LossSmartlipo® & LiposuctionLipo-Abdominoplasty (Tummy Tuck)Facial Fat GraftingButtocks EnhancementBreast Augmentation

Please tell us what you would like more information about:


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

Address:

Phone:


Website: SchillingMedicalSpa.comSchillingWomensCenter.com

Email: [email protected]

Social Media: facebook.com/johnschillingmd@drjohnschilling

Online Newsletter: issuu.com/schillinghealthcare



Medical AestheticData Form


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






If a friend, name?




Facials - Facial ServicesChemical PeelsHome Skin Care ProductsHyper-Pigmentation Rosacea

MicrodermabrasionBotox® Dysport®


Laser Stretchmark ReductionLaser Skin Tightening/Anti-Aging

Please tell us what you would like more information about:Laser Hair ReductionLaser Vein TreatmentWeight-LossSmartlipo® & LiposuctionLipo-Abdominoplasty (Tummy Tuck)

Facial Fat GraftingButtocks EnhancementBreast Augmentation

med

IcaL

hIS

torY

Breast-feedingArthritisAnemiaAsthmaBlood Pressure

CancerChronic PainDiabetesDepressionEdema

EpilepsyFatigueFibromyalgiaHeart DiseaseHIV / Aids

InsomniaNumbnessSinus ProblemsSmokerSpinal ProblemsVaricose Veins


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 YESAre you sensitive to LATEX? NO YESAre you currently pregnant? NO YESAre you attempting pregnancy? NO YESDo 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:

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Have you ever taken Accutane? NO Yes, When Dosage Amt of timeHave 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/DysportRestylane/Radiesse/Other filler? SculptraComedone (blackheads) Extraction

Laser Chemical PeelsFacial Surgeries Number of Facials in last 12 months

Even color ToneSkin PigmentationAcneSkin Hydration

Lines / WrinklesSkin ElasticitySkin textureAcne Scars

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

Areas of Concern (Please check all that apply):

LaSe

r ha

Ir r

educ

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& W

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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 TanningSunless Tan Lotions

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

conS

ent a

nd S

IGna

ture

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














Address:

Phone:






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





Address:

Phone:








Cosmetic Surgery Consultation Data Form

(IF you decide on surgery, you MUST fill out complete history form)


T (770) 474-7151 F (770) 506-1915SchillingWomensCenter.com






If a friend, name?


Facials - Facial ServicesChemical PeelsHome Skin Care ProductsHyper-Pigmentation

RosaceaMicrodermabrasionBotox® Dysport®


Please tell us what you would like more information about:Laser Stretchmark ReductionLaser Skin Tightening/Anti-AgingLaser Hair ReductionLaser Vein Treatment

Smartlipo® & LiposuctionLipo-Abdominoplasty (Tummy Tuck)Facial Fat GraftingButtocks EnhancementBreast Augmentation

med

IcaL

hIS

torY




Have you ever had liposuction? NO YES If yes, specify:Have you ever had mesotherapy or lipo-dissolve? NO YES If yes, specify:Do you have any allergies? NO YES If yes, specify:Are you currently using any oral medications? NO YES If yes, specify:Do you routinely take herbal supplements? NO YES If yes, specify:Are you taking anti-depressant or anxiety medication? NO YES If yes, specify:List any medications you are presently taking:Are you sensitive to LATEX? NO YES Are you currently pregnant / thinking in near future/ or breast-feeding? NO YES If yes, specify:Do you use birth control pills? NO YES If yes, specify:What body area is your concern?

SIGn

atur

e I have listed all known medical/physical conditions, if I decide to proceed with surgery, I know I must fill out a complete medical history form. I confirm to the best of my knowledge that the answers I have given are correct and, that I have not withheld any information that may be relevant to my consultation.

Signature Date today

Breast-feedingArthritisAnemiaAsthma

Blood PressureCancerChronic PainDiabetes

DepressionEdemaEpilepsyFatigue

FibromyalgiaHeart DiseaseHIV / AidsInsomnia

NumbnessSinus ProblemsSmokerSpinal Problems

Varicose VeinsClotting Disorders

OFFICE USE ONLY: CURRENT WEIGHT: HEIGHT:

ABDOMINAL GIRTH: BMI:NOTES:

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














Address:

Phone:




