Athena Plastic Surgery
Avron Lipshitz, MD - Stuart & West Palm Beach, FL
Natural results, Advanced Techniques, Exceptional Care
Call Us
772-324-8197
Text Us
772-985-9428
Watch Our Practice Videos
Patient Portal
Home
About
Meet Dr. Avron H. Lipschitz
Meet the Staff
Affordable Surgical Financing
Cherry Payment Plans
CareCredit Financing
Alphaeon Credit Financing
Affordable Aesthetics Financing
Tour The Facility
In the Media
Reviews
Blog
Locations
Stuart Office
West Palm Beach Office
Areas Served
Fort Pierce
Hobe Sound
Hutchinson Island
Jensen Beach
Jupiter Island
Palm City Farms
Port Saint Lucie
Sewells Point
St. Lucie West
Tequesta
Patient Resources
Patient Portal
Insurance Information
Cherry Payment Plans
Financing
Patient Forms
Patient Reviews
Pre and Post Operative Instructions
Post-Procedure Skin Care Instructions For Ablative Resurfacing Treatments
FAQ
Video Demonstrations
Gallery
Before & Afters
3D Before & Afters
Cosmetic
3D Simulated Consultations
VECTRA H2
Face
Facelift and Neck Lift
Deep Neck Lift
Blepharoplasty – Eyelid Surgery
Rhinoplasty – Nose Surgery
Brow Lift
Otoplasty
Ultherapy
Threadlifting
Breast
Breast Surgery
Breast Augmentation
Breast Lift
Breast Reduction
Breast Implant Revision
Body
Liposuction
Tummy Tuck
Mommy Makeover
Non-Invasive
EndyMed PRO Non-Invasive Skin Tightening
EndyMed Intensif Microneedling
Male Cosmetic Surgery
Injectables
Botox
Dysport
Liquid Facelift
Sculptra
Lip Injections
Dermal Fillers
Juvederm
Restylane
Voluma
Reconstruction
Breast Reconstruction
MOBILE WOUND CARE
Facial Reconstruction
Cryotherapy
Skin Biopsy
Skin Cancer Screenings
Surgical Excision for Skin Cancer
Medspa
Laser Services
CoolPeel®
CO2 Laser Treatments
IPL Treatments
Laser Genesis Non-Ablative Skin Resurfacing
Laser Hair Removal
Vanquish Me Fat Reduction
Ultherapy
EndyMed Intensif Microneedling
EndyMed PRO Non-Invasive Skin Tightening
HydraFacial
Skin Care
Spa Services
Wellness
Weight Loss
Biote
Women
Bioidentical Hormone Replacement Therapy for Women
Hormone Balance For Women
Pellet Therapy For Women
Hormone Imbalance Symptoms in Women
Men
Bioidentical Hormone Replacement Therapy For Men
Hormone Balance For Men
Pellet Therapy for Men
Pellet Therapy Benefits for Men
Hormone Imbalance Symptoms in Men
Specials & Events
Contact
LinkedIn
This field is for validation purposes and should be left unchanged.
Welcome to Athena Plastic Surgery. Dr. Avron Lipschitz is a board-certified plastic surgeon serving the Treasure Coast. Thank you for choosing us for your plastic surgery needs. We kindly ask that you fill out our patient information and medical history sheet to help us better serve you and maintain our records.
Patient Info
Patient's Name
(Required)
Date of Birth
(Required)
Age
(Required)
Marital Status
(Required)
Select
Single
Married
Widowed
Divorced
Cell or Home #
(Required)
Social Security #
Home Address
(Required)
City & State
(Required)
Zip Code
(Required)
Email Address
(Required)
(this allows us to send you appointment reminders and specials)
Reffered By
In Case of Emergency Please Notify
(Required)
Phone #
(Required)
Relationship to Patient
Patient's Employer
Occupation
Business Phone #
(Required)
Employer's Address
(Required)
Employer's City & State
(Required)
Employer's Zip Code
(Required)
Insurance Information
Primary Insurance
(Required)
Member ID
(Required)
Group #
(Required)
Relation To Insured:
(Required)
Self
Spouse
Dependent
Name of Insured
(Required)
DOB
(Required)
Secondary Insurance
Member ID
Group #
Relation To Insured:
Select
Self
Spouse
Dependent
Name of Insured
DOB
Reason for Consult
What is your reason for Consult?
(Required)
Do you have any allergies? If so, what?
(Required)
List all the medications you are currently taking. Include herbal supplements and vitmins.
(Required)
If none, please enter "none"
List any medical conditions.
(Required)
If none, please enter "none'
Past Surgical History
Please list ALL surgeries you have had and the date
(Required)
Do you smoke?
(Required)
Select
Yes
No
If yes, how many cigarettes per day?
Have you smoked in the past?
(Required)
Select
Yes
No
If yes, for how long?
Do you drink alcohol?
(Required)
Select
Yes
No
If yes, how many drinks per day?
Do you take any drugs/medications not prescribed by your doctor?
(Required)
Select
Yes
No
Medical History
Past/Current Medical History (check all that apply)
Anxiety
Arthritis
Asthma
Bleeding Problems
Bladder Problems
Blood Clots
Cancer
Diabetes
Depression
Embolism
Ear Problems
Eye Problems
Drug Dependence
Epilepsy
Hernia
HIV/AIDS
Infections
Heart Attack (MI)
Endocrine Disorders
Psychiatric
Breast Problems
Intestinal Problems
Muscle Disorder
Bone Disorders
Fractures
Vascular Problems
Seizure Disorder
Skin Disorders
Stroke
Thyroid Problems
Keloids
Kidney Problems
Liver Problems
Lung Problems
High Blood Pressure
Heart Problems
None
Do you currently have any of the following? (check all that apply)
Fever/Chills
Sore Throat
Cough
Pain
Redness
Swelling
Bleeding
Itching
Weakness
Weight Loss
Vision Changes
Feeling Tired
None
Other:
Family History (please list the relationship to the affected family member)
(Required)
BRCA Positive
Breast Cancer
Diabetes
Heart Disease
Hemophilia
High Blood Pressure
Obesity
Skin Cancer
None
Other Cancer: (Please specify)
Females: (if applicable)
Are you pregnant or possible pregnant?
(Required)
Select
Yes
No
Number of Pregnancies
Number of Children
Do you have any history of breast disease or breast cancer?
(Required)
Select
Yes
No
Do you have any acute or chronic breast pain, lumps, or discharge?
(Required)
Select
Yes
No
What was the date and findings of your last mammogram?
(Required)
Past Anesthesia History
Have you had anesthesia in the past?
(Required)
Select
Yes
No
What type of anesthesia?
Select
Local
General
Unknown
Describe any associated problems:
Are you interested in learning more about any of the following:
Botox/Dysport/Jeuveau
Eyelash Enhancement
Laser Vein Removal
Scar Revisions
Skin Care Products
Juvederm
Laser Hair Removal
Peels or Facials
Microneedling
Laser Skin Resurfacing
Radiesse
Kybella
Sculptra
Endymed/Microneedling
How did you hear about us?
Website
Magazine Ad
Friend
Physician
ER
Other
Name of referring physician/friend/website:
Name of primary care physician:
(Required)
Preferred pharmacy: (with address)
Full Name
(Required)
Today's Date
(Required)