Tavallali Plastic Surgery LLC.

3299 Woodburn Road, Suite 310, Annandale, VA 22003

5530 Wisconsin Avenue, Suite 1135, Chevy Chase MD 20815   

COSMETIC CONSULTATION REGISTRATION

Please fill out the registration below and submit so that we may better prepare for your consultation.

Check here if you have already scheduled an appointment with us.

Check here if you wish us to contact you to schedule an appointment.

Today's Date:  Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2007 2008 2009 2010

Name:

Last:          First:    Middle Initial:   

Sex:         Please Select Male Female

Address: 

Home #:   Business #:   Cell/Pager:

Email:   

Reason for today’s Consultation/Visit:

PLEASE TELL US HOW YOU HEARD ABOUT OUR OFFICE

PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY

Do you or have you had any of the following?

Surgeries

PLEASE LIST WITH DATES your previous hospitalizations, surgery, or child birth.

Allergies

Have you ever had a reaction to any medication, drug or local anesthetic?

Please Select Yes No  

If Yes Please list:

Medications

Are you now or have you ever taken any medications on a regular basis

(e.g. Aspirin, birth control pills, & vitamins Included) Please list:

PERSONAL HISTORY

Last menstrual period, if applicable: N/A January February March April May June July August September October November December 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Date of last physical examination:  N/A January February March April May June July August September October November December 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

By clicking "SUBMIT" below I confirm that:

1.  I have read and understand this form and verify that the information I have provided is accurate to the best of my knowledge. 

2.  I have had an opportunity to read the notice of privacy practices available by clicking here.

3.  I have had an opportunity to read the financial policy available by clicking here.

4.  I consent to standard medical photographs before, during and after treatment as needed. The photographs are the property of Dr. Tavallali and may be used for teaching, scientific purposes, and to show other patients surgical results.  Every effort will be made to protect your identity. If you do not wish to have your photos shown to other patients please check here.