New Patient Paperwork

Patient Information

MM slash DD slash YYYY
Please enter a number less than or equal to 9999.
Marital Status:(Required)
How did you hear about Dr Prysi? (Please give as much detail as you can)
Have you visited Dr. Prysi's website (

Medical History

In this time of rapidly expanding medical knowledge and the increasing specialization associated there within, there exists a very real risk of the specialist physician not being aware of the general health and medical background of the patient. On occasion such information may critically affect what procedures we may safely undertake on you and under what circumstances. We therefore ask that you give us the following medical information.

General Health:*(Required)
Recent Weight Change :*(Required)
Do You Get Regular Physicals:*(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
What is your consumption of ?
Have you had any Cosmetic Surgery in the Past?

Please select Yes indicating the following that you are currently or have ever been treated for and No for never:

Heart Disease
High Blood Pressure
Lung Disease
Kidney Disease
Mental Conditions
Blood Disorder

Consultation Questionaire

In which surgical procedure(s) are you interested? (Please check)

Other Procedure
Have you discussed this surgery with your family?
Are they agreeable?
Do you understand that the objective of any cosmetic operation is improvement in appearance, not perfection?
Are you aware that the results of the operation might not fully meet your expectations?
Have you had any previous cosmetic surgery?

Patient Computer Imaging

In the course of consultation and discussion with Dr. Prysi, I may have been shown or may be shown or provided certain brochures, and/or pictures on an electronic computer imaging device. I understand that those pictures and alteration of those pictures seen are solely for the purpose of illustration/discussion and to provide improved communication with the doctor. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics and health. I further understand and acknowledge that because of the obvious significant differences in how living tissues react to surgery, there may be no relationship between the electronic images created, and my actual final surgical result.

Use of the computer imaging system offers an opportunity for me to discuss my desires and to allow an improved communication with the doctor.

(Please initial 1 of the following)(Required)
MM slash DD slash YYYY