DEMOGRAPHIC INFORMATION

First Name *

Last Name *

Date of Birth * +

Home Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Occupation

Employer

Marital Status

Single

Married

Divorced

Spouse First Name *

Spouse Last Name *

Spouse Phone Number *

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone Number *

Insurance Type *

HMO	PPO
Not Sure

Insurance Information *

How did you hear about us?

Their Name *

May we thank them? *

Yes

No

WHAT BOTHERS YOU?

Which area of your body are you interested in treating? *

What bothers you about your eyes?

What bothers you about your facial fullness?

Losing Volume/Fullness	Face Appears "Tired" or "Less Fresh"
Other Other

What bothers you about your lower face?

What bothers you about your nose?

Dissatisfied with Shape	Difficulty Breathing
Unhappy with a Previous Surgery	Other Other

What bothers you about your skin?

Fine Lines and Wrinkles	Blotchy Appearance / Sun Spots
Other Other

What bothers you about your hands?

Appear Thin or Aged

Other Other

When do you wish to have your procedure? *

ASAP

Within 1 Month

Within 1-3 Months

Not Sure

PREVIOUS CONDITIONS

Do you have any of the following conditions? (Select all that apply.) *

Do you have any other medical problems or conditions?

Do you have a family or personal history of problems with anesthesia? *

Yes

No

Do you have an allergy to latex? *

Yes

No

Have you ever had surgery before?

List out any medications you take on a regular basis (including appetite suppressants, vitamins, herbal supplements, or any homeopathic treatments):

Do you have any allergies to medications?

SOCIAL HABITS

Do you smoke tobacco? *

Yes

No

Average Number of Cigarettes Per Day: *

Do you drink alcohol? *

Yes

No

Average Number of Drinks Per Week: *

Do you use recreational drugs? *

Yes

No

LEGAL AND CONFIRMATION

COMMUNICATION: By filling out and submitting this form, you agree to have your information added to the Steffen Med Spa mailing list to receive updates and offers. You may unsubscribe from the newsletter after you receive one.

AUTHORIZATION / ASSIGNMENT: I understand that I am financially responsible for all charges, whether or not coered by my insurance company. Furthermore, I permit payment directly to Caleb Steffen, M.D. for any benefits due or services rendered.

MEDICAL RECORDS: Authorization is hereby granted for release of any information required to process this claim. A copy of this authorization is as valid as the original. Authorization is hereby granted for release of pertinent information (this may include photographs, operative notes, clinic notes, and consultation notes) to a hospital or another physician's office for appriopriate continuum of care treatment as required.

PRIVACY POLICY: I acknowledge that I have received and/or have been offered a copy of JCMG's notice of privacy practices.

By signing below, you have read the above and agree: *

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Today's Date * +

Facebook	Instagram	Internet Search	Magazine Ad	Newspaper Ad
Friend	Patient	Family Member	Physician	Spa/Esthetician
Realself.com	Healthgrades	Make Me Heal	Yelp

Eyes	Facial Fullness
Lower Face	Nose
Skin	Hands
Other Other

Droopy Eyelids	Puffy Lower Eyelids
Sagging Lower Eyelids	Dark Circles/Under Eye Hollows
Lashes	Other Other

Sagging Jaw Line	Saggy Neck
Neck Falling (Turkey Neck)	Facial Folds
Thin Lips	Other

Chronic Headaches	Seizures	Heart Disease
Chest Pain	Lung Disease	Liver Disease/Hepatitis
Anemia	HIV	Strokes
Fainting Spells	High Blood Pressure	Shortness of Breath
Thyroid Disease	Ulcers	Bleeding Problems
Blood Clots	None of the Above