Online New Patient Paperwork

Gustavo E. Galante, MD
322 U.S. 41 #103
Schererville, IN 46375
Phone: (219) 322-3131
Mo–Fr: 8 a.m.–5 p.m.
Please call our office for additional hours with our Aesthetic Nurse and our Esthetician.

Gustavo E. Galante, MD
3800 Saint Mary Drive #101
Valparaiso, IN 46383
Phone: (219) 299-9300
Th: 1:30 p.m.–5 p.m.
Please call our office for additional hours with our Aesthetic Nurse and our Esthetician.

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Online New Patient Paperwork

Patient Information

First Name*

Middle

Last*

Primary Phone*

Work Phone

Cell Phone

Address*

City*

State*

Zip*

DOB*

Last 4 Digits SS*

Employer

Emergency Contact*

Phone*

Reason for Visit*

May we call you at work?*

Can we leave a message for you at home?*

Referring Doctor

Other

Internet*

Magazine*

Yellow Pages*

I, *
represent to the physician and staff that I am at least 18 (eightneen) years of age or, if not, am accompanied by a legal guardian.
I further understand that the taking of photography is an important part in the planning and evaluating of surgery, and I give permission for photographs to be taken before, during, and after my surgery for the purposes of documentation only.

Signature of Patient (or guardian) for Patient Information Section:

My typed name above serves as my signature, which verifies that the information I provided in this form is true, accurate, and current.*

Date*

Medical History

Age*

Height

Weight

Occupation

Marital Status

Are you currently using any recreational drugs?*

If yes, please list

Are you a smoker?*

How long?

Quit how long ago?

How much alcohol do you drink?*

Caffeine?*

Are you currently or have you ever used Phentermine or any other diet medication?*

Past Medical History

Do you have or have you had any of the following? Please select all that apply

Alzheimer's Disease*

Autoimmune Disease*

Anemia*

Anxiety*

Arthritis*

Artificial Heart Valve*

Asthma*

Blood Clots*

Bleeding Tendency*

Blood Transfusion*

Breathing Problem*

Bruise Easily*

Chemotherapy*

Cold Sores/Fever Blisters*

Depression*

Diabetes*

Emphysema*

Epilepsy or Seizures*

Heart Attack*

Heart Disease*

Hemophilia*

Hepatitis*

High Blood Pressure*

High Cholesterol*

Hives or rash*

Irregular Heart Beat*

Kidney Problems*

Leukemia*

Liver Disease*

Low Blood Pressure*

Lung Disease*

Mitral Valve Prolapse*

Psychiatric Care*

Radiation Treatments*

Stomach/Intestinal Disease*

Stroke*

Thyroid Disease*

Ulcers*

Cancer*

If answered "yes" to "Cancer", which type?

Have you ever had any serious illness not listed above?*

Have you or anyone in your family had any unusual reactions to anesthesia?*

Date of your last period

Are you pregnant, attempting to become pregnant, or breastfeeding?*

Please list the name and phone number of any physician(s) you are currently under the care of

Past Surgical History

Have you ever had surgery?*

If yes, please list:

Type

Year

Type

Year

Type

Year

Hospitalization?

Signature for Medical History Section:

My typed name above serves as my signature, which verifies that the information I provided in this form is true, accurate, and current.*

Medications

List all medicines and supplements you take

Medication/Supplement

How much?

How often?

Allergies

Are you allergic to any medications?*

Please list

Are you allergic to latex?*

Are you allergic to any foods?*

Please list

I certify that the above is true, correct, and complete. I am aware and accept that withholding information about my medical history could result in serious injury to me harm to those involved in my care

Patient Signature for Medications and Allergies Section:

My typed name above serves as my signature, which verifies that the information I provided in this form is true, accurate, and current.*

Date*

COVID-19 RISK INFORMED CONSENT

I, * understand that I am opting for an elective consultation/ treatment/procedure/surgery that is not urgent and may not be medically necessary. I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Heath Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that Dr. Gustavo Galante and his staff at Gustavo E. Galante, M.D. are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/ procedure/surgery and I give my express permission for Dr. Gustavo Galante and his staff at Gustavo E. Galante M.D., to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the test in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that if I have a COVID-19 infection, and even if I do not have symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/ self-isolation, additional tests, hospitalization that may require medical therapy, intensive care treatment, possible need for intubation/ventilator support, short-term or long- term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risk described herein, as well as those risks for the treatment/procedure/surgery itself.

I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term, and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure/surgery.

I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE. I VERIFY THAT MY TYPED IN SIGNATURE BELOW SERVES AS MY WRITTEN SIGNATURE.

Patient Signature for COVID-19 Risk Informed Consent Section:

My typed name above serves as my signature, which verifies that the information I provided in this form is true, accurate, and current.*

Date*

Witness