PRESTIGE Cosmetic Surgery

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PRESTIGE Cosmetic Surgery

DAVID L.J. WARDLE, M.D.,F.R.C.S.(C)

Fellow, Royal College of Physician and Surgeons
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6 Cataraqui Street, Suite 112

Kingston, Ontario CANADA K7K 1Z7
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NEW PATIENT INFORMATION

Patient OHIP #: ______Name of Family Physician: ______

Today’s Date______Marital Status ______

Name: Birth Date: _____ /_____ /_____(mm/dd/yyyy)Age:

Address: ______Sex: M / F

City: Province/State: Postal or Zip Code:______

Home: (____) Work: (____) Cell: (____)

E-mail:

Emergency Contact: Telephone: (_____)

Allergies:

How did you hear about Dr. Wardle?

Spouse’s Employer: ______Spouse’s Occupation: ______

Please put a check mark next to the procedures about which you would like to receive more information:

Surgery
___ Face & Neck Lift ___ Breast Reduction (men & women)
___ Crows Feet Correction ___Tumescent Liposuction
___ Forehead Lift ___ Tummy Tuck
___ Eyelid Lift (upper/lower) ___ Body Lifts (Trunk, Arms, Thighs, Buttock)
___ Eyebrow Transplantation ___Scar Revision
___ Lip Augmentation ____Botox
___ Dermabrasion ___Juvederm, Restylane Fillers, Perlane
___ Ear Shaping and Pinning ___Latisse
___ Hair Transplantation ___Autologous Fat Transfer
___ Eyebrow Transplantation ___Lip enhancement & wrinkle improvement
___ Breast Augmentation ___Skin Care/TCA skin peels
___ Breast Lift (minimal scar) /

Laser Treatments

___Hair Removal
___Spider Veins/Leg Veins
(men & women)
___Broken Capillaries
___Brown Spots
___Facial Redness
___Skin care Products
Please list any current Medical Conditions: ______

Please list any Medications or Herbal Supplements that you are currently taking:

______

Patient Signature Date

David Wardle Medical Professional Corporation