Your Name (required)

    Date of Birth (required)

    Sex: (required)

    Age (required)



    Home address (required)

    City (required)

    State (required)

    Zip (required)

    Home Number (required)



    Email Address

    Marital Status (required)

    Number of Children

    Where Employed?


    Education highest year completed

    Name of Spouse or Parent

    Where Employed


    Who is responsible for charges

    Emergency Contact Name (required)

    Phone Number

    What type of surgery you are interested in discussing

    Why did you select our center (required)

    If applicable, Who referred you

    May we acknowledge this referral

    Medical history is an extremely important part of your consultation. It helps to alert us to any potential problems that might interfere with your surgery.
    Please fill this out completely and accurately.

    Describe any injuries you have sustained, include dates

    List all the herbal supplements you are taking

    List all prescription drugs you are taking

    List any non prescription drugs you take (i.e. aspirin, cold tablets, etc.)

    List any diet pills you take (very important! Can cause serious problems with anesthesia)

    Please tell us about any serious illnesses you have had in the past (for example: heart disease, blood pressure problems, pulmonary disease, kidney disease, diabetes, thyroid trouble, stomach ulcers, etc.)

    Please list any operations you have had (including cosmetic surgery)

    Are you allergic to any drugs


    List any contact allergies including latex or other products

    Describe any difficulties you have had with anesthesia

    Are there any hereditary disorders in your family of significance

    If so, please list

    Do you smoke

    If so, what form and how much

    How much alcohol do you drink

    How is your general health

    Are you under a doctor’s care

    Please review the list below and check anything applicable. You may use the space provided for any explanation that you think would be helpful. Please be as complete as possible.


    Severe dryness of the eyes
    Glaucoma or blurry vision
    Recurrent severe dizziness
    Severe headaches
    Chronic sinus problems or nasal blockage
    Recurrent fever blisters
    Paralysis of the face
    Asthma or emphysema
    Chronic hoarseness
    Shortness of breath
    Chest pain
    Heart disease or high blood pressure
    Chronic abdominal problems
    Kidney or bladder problems
    Blood in bowel movements
    Blood in urine or trouble urinating
    Easy bruising
    Abnormal lump or node
    Menstrual disorder
    Unexplained weight loss
    Problems with bones or joints
    Chronic skin condition
    Emotional problems
    Complications after surgery
    Bad surgical result or unsatisfactory medical care

    Notice Concerning Complaints Complaints about physicians, as well as other licensees and registrants of the Texas Sate Board of Medical Examiners, including physician assistants and acupuncturist, may be reported for investigation at the following address: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creek Drive, Ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Assistance in filing a complaint is available by calling the following telephone number: 1 888 973 0022.

    Aviso Sobre Quejas Se pueden presentar quejas acerca de medicos, asi tambien como de ostras personas autorizadas y registradas pro la Junta de Examinadores Medicos del Estado de Texas (Texas State Board of Medical Examiners), incluyendo a ayudantes medicos y acupunturistas, para su investigation, en la siguiente direccion: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creek Drive, Ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Se puede obtener ayudra para presentar una queja llamando al siguiente numero telefonico: 1 888 973 0022.

    By signing below, I am indicating that I have read and completed this form accurately and completely to the best of my ability:

    Signature: (required)


    Dr. Tobin Registration Form
    Dr. Tobin Patient Registration Form 3