Patient History Form

Patient History Form

MM slash DD slash YYYY
MM slash DD slash YYYY
Emergency Contact(Required)
May we discuss your surgery or treatment with this contact? If not, then let us know whom to call if there is an emergency.(Required)
Can we send you emails and newsletters including our famous "Monthly Specials" and "Flash Specials"(Required)
Can we send you appointment reminders via email and text?(Required)
May we text you about Specials/Deals/Flash Sales? We also use text to communicate!(Required)

You may skip this section if you are not going to the spa. Spa Patients Please fill out the rest below.
Any NSAIDS(ibuprofen, advil, anaprox, or any others) or Aspirin in last 7 days
Are you suffering from Herpes Simplex 1 or 2 (cold sores/zoster or gential sores)
Have you recently had Sun Exposure or are using Sun Tanning Beds

Please open and acknowledge that you read our Terms of Service and Privacy Policies!

Dr. Jeneby Plastic Surgery - Terms and Conditions SpaBlack - Terms and Conditions

The Office is an elective surgical office and spa and therefore, we do not accept insurance of any kind. FMLA Leave is generally not available for purely Cosmetic Procedures. We do not guarantee employer approval for FMLA nor do we falsify documents. There is a 25$ fee , per individual request, before completing FMLA paperwork. We require two weeks notice for FMLA Paperwork. We do not guarantee 2 weeks. When submitting FMLA, please complete your portion of the paperwork first. (work duties, amount of time off)

I understand all sales are final. I am responsible for all bills being paid in a timely manner. I understand that this contract is between Plastic and Cosmetic Center, Trilogy by Jeneby (DBA Spa Black) and me.

The information you provide is confidential and is only to be used at Spa Black and The Cosmetic Center of South Texas.