Contact us for face lift plastic surgery in Knoxville, Tennessee Patient Information
Visit our AAAASF-accredited plastic surgery suite

Learn more about our AAAASF-accredited, in-office cosmetic surgery suite!

Address – convenient location in Knoxville, Tennessee

1.866.745.0531
801 Weisgarber Rd., Suite 500
Knoxville, Tennessee
37909

Patient Information

The following form will improve the quality of service and speed the registration process for patients during their initial appointment. Simply fill out the form below and we’ll have your registration before you even arrive. All your information will be kept completely confidential and we will never give your personal information to another company. If a question does not pertain to you, please write either “N/A” or “None” in those fields. Every field is required for us to accurately process your registration form.

*Please contact our office to set an appointment before submitting this form.

Thank you, and we look forward to meeting you during your first appointment!
Patient Information  
Address me as:
First Name:
Middle Initial:
Last Name:
Address:
City:
State
Zip:
Home Phone:
Work Phone:
Pager/Cell:
Age:
Birthdate:
Referred By:
Reason for Appointment:
Email Address:
   
Emergency Contact Information
Name:
Relationship:
Phone:
   
Employment Information
Employer:
Occupation:
Employment Address:
Business Phone:
Spouse's Name:
Spouse's Employer:
Spouse's Employment Address:
   
Medical History  
Height:
Weight:
General Health: Excellent     Good     Fair     Poor
Allergies:  
Drug/Substance: Type of Reaction:
Please check any of the following health conditions that apply to you:
High Blood Pressure Yes      No
Bleeding Tendency Yes      No
Asthma/Emphysema Yes      No
Kidney Disease Yes      No
Hepatitis/H.I.V. Yes      No
Heart Murmur/Arrhythmia Yes      No
Stomach/Intestinal Disorders Yes      No
Phlebitis (Blood Clot) Yes      No
Heart Disease Yes      No
Thyroid Yes      No
Diabetes Yes      No
Seizures/Migraine Yes      No
   
Do you use tobacco products? Yes      No
How much/how often?
Do you consume alcohol? Yes      No
How much/how often?
Certain prescription and non-prescription drugs (aspirin products, dietary supplements, etc.) can increase the chances of bruising.
 
Please list all medications you are taking (prescription and non-prescription):
Prescription  
Medication Amount
   
Non-prescription  
Medication Amount
Please list any surgery or hospitalizations you have had in the past (5) years:
Do you take diet pills? Yes      No
What type?
Have you been treated for an emotional disorder? Yes      No
Disorder:
Are you pregnant or trying to conceive? Yes      No
If you are at least 60 years of age, when and where was your last EKG?
I hereby give permission for photographs to be taken for my medical record. These photographs are for medical use only. Yes No

I have contacted the office for an appointment before submitting this form: Yes