Send Us Your Medical History

New Patient Submition Form:

I am interested in the following procedures:

 BOTOX® Breast Augmentation Breast Lift Breast Reduction Brow Lift Buttock Augmentation Chemical Peel Eyelid Surgery Facelift Facial Liposuction F.A.M.I. Lip Augmentation Liposuction Necklift Otoplasty Rhinoplasty Scar Revision Tummy Tuck

Are you interested in our Skin Care Program?  Yes No

Please provide the following contact information:

First Name:M.I.:Last Name:Organization:
Street Address:Address (cont.):
City:
State/Province:Zip/Postal Code:
Cell Phone:Home Phone:
Other Phone:E-mail:

Are there any restrictions on contacting you at the above phone numbers? Yes No

If so, please list:

Please identify and describe yourself:

SSNMarried ? Yes NoMarried to:
Age:Date of Birth:
Sex Male Female
Height:Weight:

Patient's Employer:

Company Name:Occupation:
Work Phone:Ext:
Is it OK to call at work? Yes No
Street Address:Suite Number:
City:
State/ Province:Zip/Postal Code:

Emergency Contact:

Name:Relationship:
Work Phone:Home Phone:
Other Phone:

Primary Health Insurance Company:

Insurance Company Name:
Policy #:Group #:Ins. Phone:
Referral Required? Yes NoCopay? Yes No
$,
Insured Name:DOB:Employer:

Please let us know who referred you.

 Friend Houston Press NuImage Health and Fitness Life Style and Homes Inside Houston Patient News Korea TV Commercial Word of Mouth Web search / Internet  Yellow Pages Staff Radio Other Vietnam Yellow Pagesif Friend, Patient or Other:

Dr. Nikko provides consultations for cosmetic procedures. I fully understand that I am financially responsible for all medical services to me at the time of services.

 Yes NoEnter Initials:

Are you allergic to any medications?

 Yes No

If so, please list:

Are you currently taking any medication?

 Yes No

If so, please list:

Personal History

How often do you drink alcohol? Never Rarely Moderately
Do you currently smoke? Yes No
If so, how often?

Pregnancies:
Date of last Period:

Have you been diagnosed with an anxiety or depression disorder in which you have received treatment or taken medication?

 Yes No
Have you ever been diagnosed with cancer? Yes No
Do you have family history of breast cancer? Yes No Unknown

Have you ever been diagnosed with:
Hepititis A, B, and/or C? Yes No Unknown
History of exposure to HIV? Yes No Unknown
Have you had cosmetic surgery before? Yes No

If yes, please list procedure and date.