Patient Form

Patient Information

First Name

Middle Name

Last Name

Email

Cell Phone

Home Phone

Work Phone

Preferred Phone

Occupation

SSN

Sex

Height

Weight (lbs)

Date of Birth

Age

# of Children

C-Section

Please list your main interests / concerns

How did you hear about The Lipedema Institute?

Home Address

Home Address

City

State

Zip

I want to add a different Mailing Address

Mailing Address

Mailing Address

City

State

Zip

Emergency Contact

Name

Phone

Address

City

State

Zip

Authorization

Due to the new HIPAA laws that are now in effect, we must have your written authorization to release your medical information to a person other then yourself. Understand that your information may need to be discussed with your current physician or any other member of your physician’s office and/or other medical facility in regards to the scheduling of procedures. Only the information needed to do this will be released. This release will be valid for one year from the date of signing.

Whon may we release your medical information to:

Spouse

Sibling

Parent

Son/Daughter

Physician

Attorney

Other

May we send you any correspondence through the mail?

Yes

No

May we leave a message on your answering machine confirming appointment or following up on any procedures done in our office that you need to call us about?

Yes

No

Surgical History

I am interested in the following:

Why are you considering Liposuction?

Have you had any previous Liposuction?

Yes

No

Year

Physician

Areas

Have you had other Fat Reduction procedure (coolsculpting, EMSculpt, lipodissolve, injections, etc.) ?

Yes

No

Year

Physician

Procedure

Have you had a Butt Augmentation?

Yes

No

Year

Physician

Please list any bad outcomes

Ethnicity

History of Skin Cancer

Type

Medical History

Please fill out each section of the medical history form. If you have had no medical problems choose [no problems].

Other Medical Problems or Disease (VERY IMPORTANT):

Past Surgical History:

Current Medications (Please list medication, dosage, how often you take them and for what medical condition):

Allergies (and type of reaction):

Photos

Please take photos in front of a plain background. For example, use a plain-colored wall or plain-colored sheet (white or blue is preferable) hung on a wall.

Image Upload

Choose Files

HIPPA Acceptance

I acknowledge that I have read & understood the Notice of Privacy Practices [HIPPA Form]

Patient's Rights & Responsibilities

I acknowledge that I have read & understood the [Patient's Rights & Responsibilities Document]

Signature

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