Facial Plastic & Cosmetic Surgical Center

Patient Registration Form (PDF)

To view the file you will need Adobe Acrobat Reader

The following information will help us to serve you better. Please make every effort to fill out the information fully and accurately. Please be sure to complete both sides of the form. Your responses are held strictly confidential.

All fields marked with a * are required:

* Name

* Date of Birth (i.e. xx/xx/xxxx)

Age

Sex

SSN (i.e. xxx-xxx-xxxx

* Address

City

State
Zip Code

Home Phone (i.e. xxx-xxx-xxxx)

Cell Phone (i.e. xxx-xxx-xxxx)

Work Phone (i.e. xxx-xxx-xxxx)

* Email (i.e. name@company.com)

Marital Status

Number of Children:

Where Employed

Occupation

Education highest year completed

Name of Spouse or Parent

Spouse or Parent’s occupation

Spouse or Parent’s employer

Emergency Contact

Emergency Relationship

Emergency Contact Phone

Who is responsible for charges

Please list the primary types of surgery you are interested in discussing.

Surgery Type

Nose

Face

Eyelid

Neck

Mouth

Ears

Scars

Cheeks

Chin

Wrinkles

Chest Enlargement

Breast Reduction

Tummy Tuck

Other

WHY DID YOU SELECT OUR CENTER? Please indicate all that apply ( ) General reputation or recommendation

Patient Referral Patient Name

May we acknowledge patient referral

Doctor Referral Doctor Name

May we acknowledge Doctor referral

Speaking Engagement

Where

Magazine

Magazine Name

Newspaper

Yellow Pages

Web site

Other

The medical history is an extremely important part of your consultation. It helps to alert us to any potential problems that might interfere with your surgery. Please take the time to fill this out completely and accurately. If you need some help, the staff will be glad to assist you.

List all the herbal supplements you are taking

List all prescription drugs you are taking

List any non prescription drugs you take (i.e. aspirin, cold tablets, etc.)

List any diet pills you take (very important! Can cause serious problems with anesthesia)

Please tell us about any serious illnesses you have had in the past (for example, heart disease, blood pressure problems, Pulmonary disease, kidney disease, diabetes, thyroid trouble, stomach ulcers, etc.)

Please list any operations you have had (including cosmetic surgery).

Are you allergic to any drugs

Please list allergies

List any contact allergies including latex or other products

Describe any injuries you have sustained, include dates

Describe any difficulties you have had with anesthesia

Are there any hereditary disorders in your family of significance

Do you smoke

If so, what form and how much

How much alcohol do you drink

How is your general health

Are you under a doctor’s care

Please review the list below and check anything applicable. You may use the space to the right for any explanation that you think would be helpful. Please be as complete as possible.

Severe dryness of the eyes

Glaucoma or blurry vision

Recurrent severe dizziness

Severe headaches

Chronic Sinus problems or nasal blockage

Recurrent fever blisters

Paralysis of the face

Asthma or emphysema

Chronic hoarseness

Shortness of breath

Chest pain

Heart disease or high blood pressure

Chronic abdominal problems

Kidney or bladder problems

Blood in bowel movements

Blood in urine or trouble urinating

Easy bruising

Menstrual disorder

Abnormal lump or node

Problems with bones or joints

Unexplained weight loss

Cancer

Emotional problems

Chronic skin condition

Complications after surgery

Bad surgical result or unsatisfactory medical care

Notice Concerning Complaints Complaints about physicians, as well as other licensees and registrants of the Texas Sate Board of Medical Examiners, including physician assistants and acupuncturist, may be reported for investigation at the following address: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creed Drive, ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Assistance in filing a complaint is available by calling the following telephone number: 1 888 973 0022.

Aviso Sobre Quejas Se pueden presentar quejas acerca de medicos, asi tambien como de ostras personas autorizadas y registradas pro la Junta de Examinadores Medicos del Estado de Texas (Texas State Board of Medical Examiners), incluyendo a ayudantes medicos y acupunturistas, para su investigation, en la siguiente direccion: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creek Drive, ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Se puede obtener ayudra para presentar una queja llamando al siguiente numero telefonico: 1 888 973 0022.

Height

Weight

Post Doctoral Clinical Fellows spend a year training at our Center. They will assist in your surgery although Dr. Tobin will always be the principal surgeon unless patients request otherwise. If, for any reason, you do not wish to have this physician present during your consultation notify a member of our staff.
I have read and complete this form completely and accurately to the best of my ability:

Date (i.e. xx/xx/xxxx)

Signature

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Facial Plastic & Cosmetic Surgical Center
6300 Regional Plaza
Abilene, Texas 79606
325-695-3630

Toll Free 800-592-4533
Fax 325-695-3633
e-mail: n41gt@newlook.com

* Name
* Date of Birth	(i.e. xx/xx/xxxx)
Age
Sex
SSN	(i.e. xxx-xxx-xxxx
* Address
City
State
Zip Code
Home Phone	(i.e. xxx-xxx-xxxx)
Cell Phone	(i.e. xxx-xxx-xxxx)
Work Phone	(i.e. xxx-xxx-xxxx)
* Email	(i.e. name@company.com)
Marital Status
Number of Children:
Where Employed
Occupation
Education highest year completed
Name of Spouse or Parent
Spouse or Parent’s occupation
Spouse or Parent’s employer
Emergency Contact
Emergency Relationship
Emergency Contact Phone
Who is responsible for charges
Please list the primary types of surgery you are interested in discussing.
Surgery Type
Nose
Face
Eyelid
Neck
Mouth
Ears
Scars
Cheeks
Chin
Wrinkles
Chest Enlargement
Breast Reduction
Tummy Tuck
Other
WHY DID YOU SELECT OUR CENTER? Please indicate all that apply ( ) General reputation or recommendation
Patient Referral	Patient Name
May we acknowledge patient referral
Doctor Referral	Doctor Name
May we acknowledge Doctor referral
Speaking Engagement
Where
Magazine
Magazine Name
Newspaper
Yellow Pages
Web site
Other
The medical history is an extremely important part of your consultation. It helps to alert us to any potential problems that might interfere with your surgery. Please take the time to fill this out completely and accurately. If you need some help, the staff will be glad to assist you.
List all the herbal supplements you are taking
List all prescription drugs you are taking
List any non prescription drugs you take (i.e. aspirin, cold tablets, etc.)
List any diet pills you take (very important! Can cause serious problems with anesthesia)
Please tell us about any serious illnesses you have had in the past (for example, heart disease, blood pressure problems, Pulmonary disease, kidney disease, diabetes, thyroid trouble, stomach ulcers, etc.)
Please list any operations you have had (including cosmetic surgery).
Are you allergic to any drugs
Please list allergies
List any contact allergies including latex or other products
Describe any injuries you have sustained, include dates
Describe any difficulties you have had with anesthesia
Are there any hereditary disorders in your family of significance
Do you smoke
If so, what form and how much
How much alcohol do you drink
How is your general health
Are you under a doctor’s care
Please review the list below and check anything applicable. You may use the space to the right for any explanation that you think would be helpful. Please be as complete as possible.
Severe dryness of the eyes
Glaucoma or blurry vision
Recurrent severe dizziness
Severe headaches
Chronic Sinus problems or nasal blockage
Recurrent fever blisters
Paralysis of the face
Asthma or emphysema
Chronic hoarseness
Shortness of breath
Chest pain
Heart disease or high blood pressure
Chronic abdominal problems
Kidney or bladder problems
Blood in bowel movements
Blood in urine or trouble urinating
Easy bruising
Menstrual disorder
Abnormal lump or node
Problems with bones or joints
Unexplained weight loss
Cancer
Emotional problems
Chronic skin condition
Complications after surgery
Bad surgical result or unsatisfactory medical care
Notice Concerning Complaints Complaints about physicians, as well as other licensees and registrants of the Texas Sate Board of Medical Examiners, including physician assistants and acupuncturist, may be reported for investigation at the following address: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creed Drive, ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Assistance in filing a complaint is available by calling the following telephone number: 1 888 973 0022. Aviso Sobre Quejas Se pueden presentar quejas acerca de medicos, asi tambien como de ostras personas autorizadas y registradas pro la Junta de Examinadores Medicos del Estado de Texas (Texas State Board of Medical Examiners), incluyendo a ayudantes medicos y acupunturistas, para su investigation, en la siguiente direccion: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creek Drive, ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Se puede obtener ayudra para presentar una queja llamando al siguiente numero telefonico: 1 888 973 0022.
Height
Weight
Post Doctoral Clinical Fellows spend a year training at our Center. They will assist in your surgery although Dr. Tobin will always be the principal surgeon unless patients request otherwise. If, for any reason, you do not wish to have this physician present during your consultation notify a member of our staff. I have read and complete this form completely and accurately to the best of my ability:
Date	(i.e. xx/xx/xxxx)
Signature