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Patient Forms

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Patient Information

Please fill out completely. Provide your name and any relevant medical information below. If you are reaching out after normal office hours, we will get back to you as soon as we can the next day.

First Name

Middle Name

Last Name

Street Address

City

State

Zip Code

Date of Birth

If minor, parent’s name:

Marital Status

Gender

Telephone

Work Telephone:

Reason for Visit:

May we send you offerings via mail / e-mail?

Yes No

Primary Referral Source:

Best Email for You

Emergency Contact Information:

Name

Relationship

Contact Number

Medical History

Height

Weight

Bra Size (For Breast Consultations Only):

Medications that you are allergic to:

Are you allergic to Aspirin?

Yes No

Are you allergic to Latex?

Yes No

Current Medications: Oral, Topical, & Herbal Supplements:

Do you Smoke?

Yes No

If so, how much?

Do you drink Alcohol?

Yes No

If so, how much?

Do you use Drugs?

Yes No

Are you Pregnant / Breast Feeding?

Yes No

Number of Children:

Number of C-Sections:

Previous Surgeries

Procedure

Year

Procedure

Year

If you have ever had a problem with Anesthesia, please explain:

Please check all of your past and current Medical Conditions:

Anemia or Blood Disorder Arthritis Asthma or other Lung Disorder Auto-Immune Disorder Cancer Cold Sores Diabetes Eating Disorder Epilepsy Eye Disease/ Dry Eyes Gastroenterology Disorder Heart Disease Hepatitis or Liver Disease High Blood Pressure Kidney Disease Nerve Disorder Skin Disorder Thyroid Disorder Urology Disorder Other

Please check all the procedures about which you would like to receive more information from our staff:

Cosmetic Surgery:

Abdominoplasty (Tummy Tuck) Blepharoplasty Breast Augmentation/Lift/Reduction Liposuction Face/Neck/Browlift Rhinoplasty (Nose Job) Mommy Makeover Labiaplasty Umbilicoplasty (belly button) Otoplasty (ear surgery) Lesion/Cyst/Nevus Fat Transfer

Non-Surgical Procedures:

Diva Botox Fillers Facial Lasers Laser Hair Removal PRP Coolsculplting MiraDry Kybella Medical Facial Chemical Peel Microneedling Hormone replacement Therapy

Office Policies

I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare and other government sponsored programs, private insurance, and other health plans to Dr. Chang. I understand that I am financially responsible for all office and emergency room charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment and assume liability for collection costs. Whether or not my insurance company pays in full, a portion, or no portion of my medical bills, is a matter between me and my insurance carrier. Unless other arrangements have been made, any unpaid balance is due within 30 days of treatment. Payment is accepted in the form of cash, check, credit card, or money order. I agree to promptly pay all charges when billed for medical services rendered and accept legal responsibility for any and all charges for payment. I hereby give my permission to have the appropriate photographs taken for the purpose of completing Dr. Chang’s records. These records are confidential and will not be presented without both my and Dr. Chang’s written permission.

Patient Signature (Parent, if minor)

Date

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19500 Sandridge Way, Suite 350, Leesburg, VA 20176
703-729-5553
[email protected]

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Important Announcement

Please note that Aesthetica Cosmetic Surgery & Laser Center will be closed on Monday, September 2, in observance of Labor Day.

We hope you enjoy the holiday, and we’ll be back to serve you with our regular hours on Tuesday, September 3. Have a safe and relaxing Labor Day!