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Patient Information Sheet
When collecting patient information this blank Patient Information sheet provides guidelines for the proper questions to ask when admitting a patient to your practice. This Patient Information form also includes a release for any photographs that may be taken while the patient is under your care.

Free Sample Template
Format: Word PDF
# of Pages: 2
Printable: Yes


Patient Information Sheet TemplateForm 1207
Format: Word PDF
Category: Medical, Hospital
Type: Form
Patient Information Sheet




Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City: _____________________________________ State: _______________ Zip Code: _______________________

Phone Number: ________________________________________________________________________________

Social Security Number: ___________________________ Date of Birth: ___/___/_____ Sex: ___ Male ___Female

Primary Care Physician: __________________________________________________________________________

Address: ______________________________________________________________________________________

City: _____________________________________ State: _______________ Zip Code: _______________________

Phone Number: ________________________________________________________________________________

Pharmacy: ____________________________________________________________________________________

Pharmacy Phone Number: ________________________________________________________________________

Emergency Contact: _____________________________________________________________________________

Emergency Phone Number: _______________________________________________________________________

Medications you are currently taking: ______________________________________________________________

_____________________________________________________________________________________________

Are you allergic to any oral or topical medications? ___ Yes ___ No If yes, what kind: ________________________

_____________________________________________________________________________________________

List all serious illness, medical conditions, and past surgeries: ___________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Do you have a history of (Please check all that apply)?

___ Bleeding disorder ___ Keloid scars ___ Poor healer ___ Hyperpigmentation ___ Large Hypertrophic scars


Describe your skin reaction when exposed to the sun:

___ Always burns, never tans

___ Sometimes burns, tans with difficulty

___ Rarely burns, tans with ease

What would you like treated?

___ Leg veins ___ Tattoos ___ Warts ___ Brown spots ___ Scars ___ Striae marks ___ Facial veins ___ Hair removal

___ Wrinkles ___ Liposuction ___ Other: ____________________________________________________________


Patientís Signature: ___________________________________________________________ Date: ___/___/_____

Photograph Consent

We will routinely take photographs to document treatment results. Occasionally, we might use the images for teaching or to publish in scientific articles. These photographs will not be used for advertising without first contacting you and receiving your permission. If your photograph is used will have you sign an additional consent form.

I do hereby agree to have photographs taken for the above stated reasons.

Patientís Signature: _____________________________________________________________________________

Please exclude the following: _____________________________________________________________________

_________________________________________________________________________________________