Patient History Form

Medical History Form

Our patient history form is available for download (pdf).  It is very important that Dr. Brackup and Dr. Hubert understand your complete health history since this may impact cosmetic or plastic surgery procedures.  In order to save time during your office visit, please print the form, fill out both pages as completely as possible, and bring it with you to the office.  This history form includes questions regarding other medical conditions, previous surgery, current medications, and allergies.  The history form also contains a place for emergency contact information and basic demographics. 

Please note that all of your information is kept strictly confidential, and our office complies with existing protected health information and HIPAA guidelines.

In order to view a pdf file, you must have Adobe Acrobat Reader installed on your computer. If you do not already have it installed, you can download it from Adobe's website by clicking here.