Medical History Form

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Name *

First

Last

Phone Number *

Email *

Age *

that Name information

Height *

Weight *

DOB *

Have you ever been seen by Dr. Loftus *

Smoker? How many packs per day? *

Prescription Medications *

Supplements *

Aspirin/NSAIDS *

Allergies to any medications *

Please check all that apply *

Other medical problems not listed above *

List ALL past surgeries *

Enter full name to certify that the above information is complete and accurate *

Loftus Total Skin Care

ADDRESS:

1881 Dixie Highway, Suite 300
Fort Wright, KY 41011

PHONE:

859.426.5100 and 513.821.8700

HOURS:

Mon-Thurs: 9-5, ET
Fridays: 9-12, ET