New Patient FormPlease fill out this form before your first appointment at Fusion. Name * First Name Last Name Birthday * Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact (Name, Relation, and Phone number) Medical History (Check all that apply) High Blood Pressure Heart Disease Asthma Diabetes Thyroid Problems Oesteoporosis Abnormal Pap Other If other, please list below. Please list any prescriptions, over the counter medications, vitamins, and supplements. Have you had any surgeries No Yes If yes, then please list year(s) & surgeries below: Are you allergic to any medications? No Yes If yes, please list below. Do you use tobacco products? * Never Quit Yes, Currently Type of tabacco products: Number of days per week: 0 1 2 3 4 5 6 7 Number of years using tabacco: Do you drink alcohol? No Yes If yes, how often? Other drug use? Never Quit Yes Current symptoms (check all that apply) Weight change Fever Change in appetite Fatigue Shaking chils Night Sweats Weakness Chest Pain Irregular heartbeat Rapid heartbeat Swelling in legs Frequent urination Leaky bladder Heat or cold intolerance Loss of libido Vaginal dryness Vaginal laxity Excessive hunger Erectile problems Depression Anxiety Drug abuse Alcohol abuse Difficulty concentrating Difficulty sleeping Loss of interest in activities usually enjoyed Joint stiffness or pain Joint swelling Back pain Limitation of movement Muscle pains or cramps Aesthetic Procedures I've previously had (check all that apply): Botox/Dysport/Xeomin Fillers (undereye, lips, etc.) Coolsculpting I understand that all sales are final once payment is made. Fusion does not offer refunds. * I agree Thank you for submitting your new patient form!
