About this template
Streamline your pre-procedure workflow with this comprehensive Plastic Surgery Patient Intake Form, designed to capture vital health history, current medications, allergies, and lifestyle factors before consultations or surgeries. Collecting detailed medical information in advance helps clinical teams screen for contraindications, minimize procedural risks, and ensure every patient is fully informed.
Built for plastic surgery practices, medical spas, and cosmetic clinics, this template covers demographic details, emergency contacts, vital signs, existing medical conditions, and COVID-19 screening. It also includes dedicated sections for surgical history and informed consent acknowledgments. With Doc2Form, you can instantly turn documents like this into fully editable Google Forms, cutting down on clipboards and manual data entry.
Key features
- Collect complete medical history and current medication lists securely.
- Screen for pre-existing conditions, allergies, and lifestyle risk factors.
- Capture emergency contact details and planned procedure information.
- Include pre-procedure disclosures and electronic signature acknowledgments.
- Reduce clinic wait times by letting patients submit intake forms in advance.
Use cases
- New patient consultations for elective cosmetic procedures.
- Pre-operative health screenings and risk assessments.
- Medical spa intake and treatment consent collection.
What this form collects
- Full Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Enter your date of birth.
- Gender (Dropdown)Select your gender identity.
- Phone Number (Short answer)Provide a reliable mobile or daytime phone number.
- Email Address (Short answer)Where can we send appointment confirmations and follow-up care info?
- Home Address (Paragraph)Enter your street address, city, state, and zip code.
- Emergency Contact Full Name (Short answer)Name of the person we should contact in case of an emergency.
- Emergency Contact Phone (Short answer)Direct phone number for your emergency contact.
- Relationship to Emergency Contact (Short answer)E.g., Spouse, Parent, Sibling, Friend.
- Planned Procedure or Service (Short answer)Specify the cosmetic or reconstructive procedure(s) you are interested in.
- Height and Weight (Short answer)Enter your approximate height and weight.
- Blood Pressure (Short answer)If known, enter your recent blood pressure reading.
- Are you currently pregnant or breastfeeding? (Multiple choice)This is critical information for surgical clearance.
- Smoking Status (Multiple choice)Nicotine use significantly impacts healing and surgical outcomes.
- Alcohol Use Status (Dropdown)Select your frequency of alcohol consumption.
- Current Medications List (Paragraph)List all prescription medications, OTC drugs, vitamins, and herbal supplements you currently take.
- Allergies Details (Paragraph)List any known allergies to medications, latex, adhesives, or foods, along with your reaction.
- Medical Conditions and Surgical History (Paragraph)List any chronic illnesses, bleeding disorders, heart conditions, or past surgeries.
- How did you hear about us? (Dropdown)Select the primary source that led you to our practice.
- Patient Signature (Type Full Name) (Short answer)By typing your full name below, you certify that all information provided is accurate and true to the best of your knowledge.
- Date Signed (Date)Enter today's date.
FAQ
How do patients access and fill out this form?
Once generated in Google Forms, you can share the link via email, text message, or embed it directly on your clinic's website for patients to complete before their visit.
Can I customize the medical questions and procedures listed?
Yes! Because the form lives in your Google Drive, you can easily add, remove, or edit any questions to match your clinic's specific surgical offerings and protocols.
How does Doc2Form help me create this form?
Doc2Form instantly converts static medical intake documents and PDFs into fully structured Google Forms, saving you hours of manual questionnaire building.
Can patients sign their consent and acknowledgment agreements?
Yes, the form includes text-based signature and date fields where patients can legally acknowledge terms and sign off on their submitted health history.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.