Tell a friend about us!

Follow Us

Buckingham Center for Facial Plastic Surgery

Edward D. Buckingham, M.D.

512.401.2500 | 512.401.2501

Se habla Español

2745 Bee Cave Rd #101 Austin, Texas 78746 | Map It

Our Practice
- Our Physicians
- Fellows
- Consultation
- Mission
- Offices
- Organizations
- Our Staff
- Disclaimer
- News
- Patient Forms
- Videos
- Blog
Surgical
Non-Surgical
Photos
- Surgical
- Non-Surgical
  - Acne Scarring
  - Belotero
  - Birthmarks
  - Botox
  - Juvederm
  - Lasers
  - Radiesse
  - Restylane
  - Sculptra
  - Spider Vein
FAQs
Testimonials
Specials
Contact Us

Forms » Health History Questionnaire

Health History Questionnaire

Your privacy is important to us! Your personal information will not be shared with anyone outside of our organization for any reason.

Patient Name (Full Name)*
Date of Birth*
Height
Weight
Please describe any concerns you would like to discuss at your appointment.*
Medications/Medical Treatment*
Please list all Medication Allergies and Reactions.
Do you take Aspirin or any blood thinners (Aleve/Ibuprofen/Fish oil) daily? If so, please describe.*
- Yes
- No
Do you use Accutane or have you used Accutane within the last year?
- Yes
- No
Do you currently use a Retin-A or Tretinoin?
- Yes
- No
Please list all medications you are currently taking including all herbal supplements.*
Are you currently under the care of a physician for any condition? If yes, please describe.
- Yes
- No
Do you have a history of any of the below conditions? If yes, please describe.
Skin Cancer
- Yes
- No
Heart Disease
- Yes
- No
Heart Arrhythmia
- Yes
- No
Lung Disease
- Yes
- No
Thyroid Disease
- Yes
- No
Shortness of breath with stairs
- Yes
- No
Chest Pain
- Yes
- No
Sleep Apnea
- Yes
- No
Diabetes
- Yes
- No
Difficulty Healing or Scarring
- Yes
- No
Hepatitis A/B/C
- Yes
- No
HIV
- Yes
- No
Seizure/Stroke
- Yes
- No
Pollen Allergies
- Yes
- No
Depression/Other Psychological Disorders
- Yes
- No
Lasik Eye Surgery
- Yes
- No
Dry Eye
- Yes
- No
Please list and all previous surgeries with approximate date
Have you had any complications from anesthesia? If yes, please describe.
- Yes
- No
Social History
Do you smoke, vape, or use any form of nicotine? If yes, please describe.*
- Yes
- No
Do you drink alcohol? If yes, how much?*
- Yes
- No
Do you use illegal substances?*
- Yes
- No
Are you currently pregnant or breastfeeding?
- Yes
- No
Cosmetic History
Have you had any non-surgical treatments (Botox, Fillers, Lasers, Peels)? If yes, please describe.
- Yes
- No
Describe your history of sun exposure.
Are you interested in any non-surgical treatments?
- Dermal Fillers (Juvederm, Voluma, Volbella, Vollure, Restylane, Restylane Silk, Sculptra)
- Neuromodulators (Botox/Dysport)
- Laser Treatments (BroadBand Light/Photofacial, Halo)
- Chemical Peels
Do you currently use a skincare regimen? If yes, please describe
- Yes
- No
Would you like to be added to our email list to receive monthly special?
- Yes
- No
*
- I accept the Terms of Use *

CONTACT DR. BUCKINGHAM

First Name*
Last Name*
Phone*
Email*
Comments
I prefer to be contacted by
- Email
- Phone
OR
512-401-2500
- Receive Our Monthly Special
*
- I accept the Terms of Use *
Name
This field is for validation purposes and should be left unchanged.

Menu of Services

Light Chemical Peel
BBL™ (Photofacial)
BBL™ ULTRA PEEL
Belotero®
Brown Spots
PCA Skin®
BOTOX®
Dysport®
Radiesse®
Restylane®
Restylane Lyft®
Juvederm®
Voluma®
Vollure XC
Volbella
Halo™ Laser
Restylane Silk

Buckingham Center Videos

Buckingham Center Videos, Austin Texas

View More Videos

Reviews

I loved my results with Dr. Buckingham and his skilled staff. My procedure was easy and painless, with an easy, short recovery leaving me with a great result that will last for years. I chose Dr. Buckingham because a friend, who is in the medical profession herself, had him perform her…

5 stars

Real patient

I thoroughly enjoyed my experience with this office! Everyone was so kind, helpful and I am extremely happy with my results.

5 stars

Real patient

Dr. Roy, nurses & the lovely ladies in the front- my entire experience at BCFPS has been wonderful. From my very first appointment, I felt welcomed and comforted. Thank you, thank you! Kindly,

5 stars

J.D.

Buckingham Resources

based on 502 reviews

Testimonials

Dear Dr. Buckingham,
What a wonderful surprise to see a box of flowers at our front door when we returned from Austin yesterday. The coral roses are gorgeous and smell wonderful! Would like to express my appreciation to you and your staff for making me feel very

See more testimonials

Directions

Directions for Buckingham Facial Plastics Surgery, Austin TX

Dr. Edward Buckingham is a Board Certified facial plastic surgeon who specializes in rhinoplasty, facelifts, eyelid surgery, and many other cosmetic facial procedures.
His office is located in Austin, Texas and services the surrounding areas including: Sunset Valley, West Lake Hills, Cedar Park, Round Rock, and many of the other nearby Texas cities.
Dr. Buckingham is also an expert in the Austin metropolitan area on RealSelf.

© 2018. Buckingham Center for Facial Plastic Surgery | Privacy Policy | By: Dr. Edward Buckingham | Website Design and SEO by Surgeons Advisor