CHICAGO | 312-751-2112

WINNETKA | 847-446-7562

New Surgical Patient Forms

Please provide the information below to register as a new surgical patient.

Patient Registration and Consent For Treatment Form

Patient Name
Preferred First Name
Gender
Address
Marital Status
DID YOU VISIT OUR WEBSITE AT JOHNQCOOKMD.COM?
JOIN THE PRACTICE MAILING LIST.
I agree to join the practice mailing list to receive practice news and VIP specials on treatments and products.

Referral Information

Referral Source 1 Name
Address (if available)
Referral Source 2 Name
Address (if available)

Emergency Contact Information

Emergency Contact
Name of Spouse
Spouse's Employer

Employment Information

Name of Occupation - Company/School

Insurance Information

Insurance
Address of Insurer
Policy Information
Signature for Authorization
I authorize John Q. Cook, MD to furnish information on conditions he has treated me for to my insurance carrier. I assign to Dr. Cook all payments for medical services rendered by him for me or my dependents. I understand that I am responsible for any amount billed and not covered by my insurance. A photocopy of this authorization and assignment is considered as valid as the original.
MM slash DD slash YYYY
Authorization to Release Information
I hereby authorize John Q. Cook, M.D. to release any information acquired in the course of my examination or treatment.
MM slash DD slash YYYY

Medical History

Patient Name
May I send a thank-you letter to them?
Do you know anyone who has undergone the procedure you are interested in?
Have you done any reading about the procedure you are interested in?
Have you ever had a plastic surgery procedure before?
Have you ever undergone surgery?
Did you have any unusual experiences after previous surgery, such as bleeding, reactions to medications, prolonged hospitalization or any departure from the expected postoperative course?
If you have had previous surgery, did any medications make you nauseated?
Do you have a history of cold sores/fever blisters / fever blisters / herpes?
Are you allergic to or have a sensitivity to any medication?
Have you ever been diagnosed with sleep apnea?
Have you ever had an allergy to Latex?
Did you ever have an unusual reaction to anesthesia?
Is there a family history of unusual reaction to anesthesia?
(such as malignant hyperthermia)?
Do you have a history of nausea from pain medication?
Do you have any unusual reactions with other medications?
Do you get lightheaded or faint when giving blood?
Do you get car sick or motion sickness easily?
Do you experience lightheadedness after meals?
Are you apprehensive or nervous about medical procedures?
Does your dentist have a hard time blocking your nerves for dental procedures, where multiple injections are required before you feel numb?

Do you have any of the following medical conditions or any past history of these conditions?

Arthritis
Asthma or other lung disease
Pulmonary Embolism
Autoimmune Disease
Bleeding disorder
Blood Clots in Legs
Chest Pain
C.Diff or Antibiotic Associated Diarrhea
Diabetes
Depression
Easy bruising
Heart failure or other heart problems
High Blood Pressure
HIV or other immune deficiency
Low Blood Sugar
Lupus
Mitral valve prolapse
Polio
Rheumatic Fever
Scleroderma
Shortness of breath
Substance abuse
Thyroid disease
TMJ (Temporo-Mandibular Joint)
Other Psychiatric Disorders

Medical/Lifestyle History

Do you have any other medical conditions which regularly bring you to a doctor?
Do you have any other medical conditions which regularly bring you to a doctor?
Do you smoke cigarettes or have a history of regular smoking in the past year?
Do you drink alcohol?
Do you take large doses of any vitamins (especially vitamins A or E)?
Have you in the past 12 months taken the drug Acutane or estrogens?
Have you in the past 12 months taken the drug Acutane or estrogens?
Do you have a tendency to form keloids, hypertrophic, thick scars or dark spots around surgical incisions or areas of injury?
Do you take aspirin, aspirin-like compounds?
Motrin, Advil, Nuprin, Ibuprofen, Naprosyn, etc. Or aspirin containing preparations such as Bufferin, Anacin, Excedrin, Dristan, Midol, Empirin, Alka Selzer, Fiorinal, Perdocan?
Are you currently on or have been on the human chorionic gonadotropin diet or HCG diet?
Name of Family Physician or Internist:
Name of Obstetrician/Gynecologist:
To the best of my knowledge the above information is correct. I realize that by giving false information on this questionnaire may adversely affect the care I receive from Dr. Cook.
MM slash DD slash YYYY
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Practice Blog

Learn more about Dr. John Q. Cook and the non-surgical treatments and plastic surgery procedures available at The Whole Beauty® Institute. Get tips and advice, discover new ways to improve your health and beauty, and more.

Dr. Cook's HealthGems Blog

Dr. John Q. Cook shares his personal thoughts on well-being, quality of life, and more—all drawn from his decades of experience in the industry, studying and working with advanced technology and techniques.

Whole Beauty Skincare

SkinShopMD was created by Chicago Plastic Surgeon Dr. John Q. Cook as a trusted source for skin health products and information. From his years of experience, he developed a portfolio of high-quality medical grade products to protect and rejuvenate your skin.

Education

Learn important information about surgical and non-surgical procedures to help you make informed decisions about your desired treatment based on your goals. Topics cover facial surgery, injectables, lasers, breast surgery, body contouring, and other treatments.

Testimonial and Practice Videos

Visit our Video Gallery to View More

Our Office Locations

Our locations in the Gold Coast of Chicago and Winnetka in the North Shore reflect our commitment to convenient and discrete concierge-level service.

The Whole Beauty® Institute location led by Dr. John Q. Cook in Chicago's Gold Coast

Chicago Office

737 North Michigan Ave., Suite 760 Chicago IL 60611 (312) 751-2112 Entrance at 151 E. Chicago Avenue

The Whole Beauty® Institute location led by Dr. John Q. Cook in Winnetka of the North Shore

Winnetka Office

118 Green Bay Road Winnetka IL 60093  (847) 446-7562
Located directly across from Indian Hill Metra Station