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Scottsdale: 480-951-4343

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About
Procedures
Gallery
- Before & After Photos
- Video Gallery
Patient Resources
Out-of-Town Patients
Blog
Contact Us
Schedule Now

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Welcome to our practice!

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Today's Date*

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First Name*

Middle Initial*

Last Name*

SSN*

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Emergency Contact*

Emergency Contact Phone*

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We encourage you to select any/all goals you have, even if unrelated to your consultation. This will allow Dr. Mazaheri to address all concerns with you and see how we can help you achieve a more confident, radiant self.

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Learn more about injectables like Botox and Juvederm?*

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Patient Signature*

Date*

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Health History

Todays Date

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Birthday*

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Purpose for Today’s Visit:*

All Previous Surgeries (include year):*

Health Problems (Past & Present):

Diabetes

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Easy Bruising

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Vaginal Dryness

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More Information*

Do you smoke?*

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Are you currently on any weight loss mediation? (Ozempic, Semaglutide, Mounjaro, ctc. )*

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If yes, how many packs per day?*

Please list all current medications (include over-the-counter, supplements, and vitamins)*

List all allergies*

Allergy to Latex?*

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Primary Care Doctor*

Date of Last Physical*

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Date*

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Patient Signature

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Office Phone:
480-951-4343

Via Fax:
480-970-3100

Via Email:
office@drmazaheri.com

480-951-4343

6865 E Becker Ln
Suite 100
Scottsdale, AZ 85254

Monday – Friday: 9am-4pm

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