New Patient Intake Form | Dr. Mahsa Sohrab

I. PATIENT INFORMATION

First Name:

Last Name:

DOB:

Address:

City:

State:

ZIP:

Email:

Cell Phone:

Home Phone:

Preferred Contact:

Email Text Phone

Join Mailing List:

Yes No

Marital Status:

Single Married Widowed

II. EMERGENCY CONTACT & REFERRAL

Emergency Contact Name:

Emergency Contact Phone:

How did you hear about us?

III. PHARMACY & PRIMARY CARE

Primary Care Physician:

Physician Phone:

Pharmacy:

Location (Town/City):

IV. MEDICAL HISTORY & MEDICATIONS

Current Medications:

Do you use GLP-1/Weight Management Injections? (e.g., Ozempic, Wegovy, Mounjaro, Compounded)

No Yes

If Yes, Specify:

Drug Allergies:

Smoking Status:

No Yes

Frequency (if smoker):

V. SURGICAL HISTORY

Previous Surgeries:

Have you ever had complications with local or general anesthesia?

No Yes

If yes, explain:

PRIVACY & COMMUNICATION

Per HIPAA regulations, your health information is kept private. This waiver allows Mahsa A. Sohrab, MD to share or receive your medical data only as specified below.

Voicemail Consent: I authorize the office to leave voicemails regarding my health information.

YES NO

CONSENT FOR PHOTOGRAPHY

I grant permission to the staff of Mahsa A. Sohrab, MD to take photographs of me for the following purposes:

Clinical Records: To document my response to treatment and assist in clinical decision-making. (Required for treatment)
Educational & Social Media: Optional.

Educational & Social Media: I authorize the use of my photographs (with my identity protected where possible) for educational purposes, the practice website, and social media platforms.

YES NO

FINANCIAL POLICIES

Cancellation and No-Show Policy:

We value your time and prepare extensively for your visit. Therefore, a $250 fee applies to no-shows or cancellations of cosmetic appointments with less than 24-hour notice.

Surgical Appointments:

A non-refundable $750 deposit is required to secure your surgical appointment. We kindly ask for at least 10 days' notice for any rescheduling or cancellation. Please ensure your balance is paid in full no later than 15 days before your surgery date; if payment is not received by this time, the appointment will be automatically canceled.

Payment Methods: We accept cash and all major credit cards as payment forms.

ACKNOWLEDGEMENT OF UNDERSTANDING OF POLICIES

I have read, understood, and agree to all the above financial policies and office policies of Mahsa A. Sohrab, MD. I certify that the information provided is correct to the best of my knowledge.

Patient Signature:

Date:

COSMETIC PATIENT INTAKE FORM

I. PATIENT INFORMATION

II. EMERGENCY CONTACT & REFERRAL

III. PHARMACY & PRIMARY CARE

IV. MEDICAL HISTORY & MEDICATIONS

V. SURGICAL HISTORY

PRIVACY & COMMUNICATION

CONSENT FOR PHOTOGRAPHY

FINANCIAL POLICIES

ACKNOWLEDGEMENT OF UNDERSTANDING OF POLICIES