Eric Mariotti M.D. - Plastic & Reconstructive Surgery
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Dr. Eric Mariotti, M.D.
2222 East St, Suite 310
Concord, CA 94520
925-685-4533

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Online Registration
You may download and print a pdf form which you can fill out and mail/bring with you, or you can register online below.

    Patient Information

  Patient First Name:  
  Middle Initial:  
  Patient Last Name:  
  Patient Nickname:  
  Sex:  
male   female
  Date of Birth (MM/DD/YY):
Please add slashes		  
  Age:  
  Status:  
Married
Divorced
Legally Separated
Other
  Social Security (no dashes):  
  Patient E-Mail:
(valid email is required)		  
  Address 1:  
  Address 2:  
  City:  
  State:  
  ZIP:  
  Home Tel (no dashes):  
  Bus. Tel (no dashes):   Ext.
  Driver's License:  
  Emergency Contact:  
  Emergency Phone (no dashes):  
  Cell Phone:  
  Work Phone:  
  Patient is Guarantor:  
Yes   No
  Primary Care Physician:  
  How did you hear about Dr. Mariotti:  
  Have you ever been a patient in our practice:  
Yes   No

 

   Account Information

  Who will be responsible for your account?  
Self   Other
  Name (if other than self):  
  Address 1:  
  Address 2:  
  City:  
  State:  
  ZIP:  
  Home Tel (no dashes):  

 

   Primary Medical Insurance (If cosmetic, insurance name will suffice)

  Employer:  
  Address 1:  
  Address 2:  
  City:  
  State:  
  ZIP:  
  Bus. Tel (no dashes):  
  Insurance Company Name:  
  Type of Coverage:  
PPO
HMO
Medicare
Other
  Group No.:  
  Insured Person:  
  Relation:  
  Sex:  
male   female
  Date of Birth (MM/DD/YY):
Please add slashes		  

 

   Secondary Medical Insurance

  Insurance Company Name:  
  Group No.:  
  Insured Person:  
  Relation:  
  Sex:  
male   female
  Date of Birth (MM/DD/YY):
Please add slashes		  
  ID No.:  

 

   Health History

 

Please fill out the health history to the best of your knowledge

All patient information is confidential.

Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
  Reason for visit :  
  Height:  
  Weight:  
  List all medications you are taking:  



  Have you taken any of the following in the last 2 weeks:  
Aspirin   Yes   No
Ibuprofen   Yes   No
Vitamin E   Yes   No
Herbal Remedies
(St John’s Wart, Ginko Biloba, Echinacea, etc.)		   Yes   No
Non prescription, birth control, cold remedies, etc.   Yes   No
  List all hospitalizations, operations (including plastic surgery, biopsies or childhood surgeries) and serious injuries.  
Year   Hospitalization/Operation/Injury
 
 
 
  Allergies  
Penicilin   Yes   No  
Other medicine   Yes   No  
Iodine   Yes   No  

 

   Illness & Medical Problems

  Heart disease  
Yes   No
  High blood pressure  
Yes   No
  Bleed easily  
Yes   No
  Bruise easily  
Yes   No
  Bleeding disorder  
Yes   No
  Heart attack  
Yes   No
  Heart murmur  
Yes   No
  Other heart conditions  
Yes   No
  Diabetes  
Yes   No
  Trouble w/ anesthesia  
Yes   No
  Arthritis  
Yes   No
  Anxiety disorder  
Yes   No
  Ulcer  
Yes   No
  Colitis  
Yes   No
  Diverticulosis  
Yes   No
  Other bowel problems  
Yes   No
  Hepatitis  
Yes   No
  Convulsions/seizures  
Yes   No
  Asthma  
Yes   No
  Bronchitis  
Yes   No
  Emphysema  
Yes   No
  Pneumonia  
Yes   No
  Tuberculosis  
Yes   No
  Other lung problems  
Yes   No
  Headaches  
Yes   No
  Dizzy spells  
Yes   No
  Glaucoma  
Yes   No
  Dry eyes  
Yes   No
  Other eye problems  
Yes   No
  Ear troubles  
Yes   No
  Sinus troubles  
Yes   No
  Women (breast proc only)
  Tender breasts  
Yes   No
  Nipple discharge  
Yes   No
  Any lumps  
Yes   No
  Last mammogram  

 

   Family History

  Tuberculosis  
Yes   No
  Asthma  
Yes   No
  Glaucoma  
Yes   No
  Cancer  
Yes   No
  Diabetes  
Yes   No
  Arthritis  
Yes   No
  Heart Disease  
Yes   No
  High Blood Pressure  
Yes   No
  Blood Disorders  
Yes   No

 

   Social History

  Use of Alcohol  
Never    
Occasional    
Daily    
  How many drinks per day  
  Tobacco  
Never    
Quit    
Yes    
  How many packs per day  
  Number of years  
  Drugs  
Never    
  Type  
  Frequency  
  Coffee  
No    
Yes    
  Number of cups  

 

   Are you interested in any of the following? (Check all that apply)

  Cosmetic Surgery:
  Breast Augmentation
  Breast Lift
  Breast reduction
  Tummy Tuck
  Liposuction
  Plastic Surgery after Massive Weight Loss
  Face Lift
  Forehead Lift
  Eyelid Lift
  Ear Pinning
  Nose Reshaping
  Restylane/Juvederm
  Botox
  Non Surgical Rejuvenation:
  Restylane/Juvederm
  Botox
  Skin Care:
  Chemical peels
  Facial products
  Acne products
  Eyelash enhancer

 

  
Cosmetic Plastic Surgery, Breast Augmentation, Reduction & Liposuction   Member American Society of Plastic Surgeons
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