Demographics

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

    Patient Information

    MaleFemale

    SingleMarriedOther

    YesNo

    How did you hear about Dr. Theunissen?

    YesNo

    Emergency Contact


    Cosmetic procedures are NOT covered by insurance. When scheduling your procedure a deposit will be required. Any remaining balance will be due at your pre-op visit approximately three weeks in advance of your surgery date. If cosmetic fees are not paid in full at that time, your surgery will be canceled. Dr. Theunissen spends a considerable amount of time in describing the elective nature of these procedures. Because you are fully informed of all limitations and risks of the procedure, we do not provide refunds for services already provided.



    Confidential Record

    Information contained here will not be released except when you have authorized us to do so. Please answer all questions to the best of your knowledge. The information provided by you will be used by your doctor in decisions regarding your care.



    Do you have or have you had:

    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    With CPAPWithout CPAP
    YesNo
    YesNo
    YesNo
    YesNo
    Type1Type2Insulin Resistance
    YesNo
    HypothyroidHyperthyroid
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo


    WOMEN ONLY

    YesNo
    YesNo
    YesNo
    I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.