Responsible Party (if different from patient) Name: Relationship to patient: Phone: Address:

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Gilbert Small
5 years ago
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1 New Patient Demographics Form Appt time: Arrival time: Name: Date of Birth: (Please Print First, M, Last) Sex: Female Male Marital Status: SSN: Home Address: Preferred Phone Number: Alternate Phone Number: Responsible Party (if different from patient) Name: Relationship to patient: Phone: Address: Emergency Contact: Name: Phone: Relationship to patient: How did you hear about us? (Please check all that applies) Your Insurance Another Physician Friends or Family: Website Other : Preferred Language: Race: White Black/African American American Indian or Native Alaskan Asian Native Hawaiian/Pacific Islander People of Two or More Races Ethnicity: Hispanic/Latino Non-Hispanic/Latino Unspecified Pharmacy: Name: Address or cross street: Primary Care Physician: phone: Fax: Referring Physician: phone: Fax: Please check all that interest you? Recommendations and/or Skin Care Products/ Improvement of complexion (acne or rejuvenation) Botox for Prevention and Treatment of Facial Wrinkles for Prevention and Treatment of Facial Folds and Facial Volume Loss or: Wrinkles/ Skin Rejuvenation/Skin Resurfacing Sun damage and Aging Facial Redness/Rosacea Brown spot/red Spots Scars/ Acne Scars Hair reduction Stretch marks Teeth Whitening Smile Makeover Introduction to Our Dental Clinic What skin care products are you currently using? For Office Use Only: Front Clinical Complete

2 Patient Name: Date of Birth: / / Today s Date: / / PAYMENT/FINANCIAL POLICY: All Patients: We follow insurance carrier s guidelines for PPO insurance plans. It is your responsibility to provide copies of current and accurate insurance information, including updates or changes in carriers or primary insured. Should you fail to provide this information, you will be financially responsible for all charges incurred. You are responsible for knowledge of your own insurance benefits including but not limited to deductible, co-insurance, co-pay details, and if the doctor you are seeing is listed as participating, and in-network, under your insurance plan. We accept payment in the form of cash, check, or credit card. In the event that the balance on your account must be turned over to collections a $30.00 or 30% collection fee (whichever is greater) will be added to your balance. In addition, at that time, you will be considered a cash patient for the future visits, therefore, payment in full will be due at the time of each service. In order for us to see you in an efficient manner, we depend on our patients to be prompt and to notify us 24 hours in advance if there are any problems with keeping their appointment time. Therefore, we will charge a no-show fee of $45 if an appointment is not cancelled 24 hours in advance. In addition, if a patient arrives more than 15 minutes after the appointment time, we may need to reschedule. We charge a $150 cosmetic consultation fee that will go towards any cosmetic treatment done on the same day. We reserve an extended time for all cosmetic & laser procedures, therefore, we require a deposit to secure your appointment. This deposit will be directly applied towards your treatment cost. However, if you do not cancel your appointment 5 business days in advance, you will be considered a no-show, and you will lose your deposit. The deposit ranges between $100- $500 (depending on the amount of time reserved for you. PPO or other managed care patients: You will be responsible for paying your annual deductible, co-payment, coinsurance and charges for any non-covered, cosmetic services at the time of service. HMO s and MEDI-CA: We will not accept Medi-cal and or HMO plans (except MHO) as a primary or secondary plan. You will be considered a cash patient and the entire balance is due at the time of service or after your primary insurance has paid. Medicare Patients: We are participating providers of the Medicare program. Patients are responsible for meeting their annual deductible and paying for the 20% co-payment. We do file with secondary /supplemental carriers. However, in the event that the secondary does not pay within 60 days, patients will be balance billed. If you have an HMO as a secondary, the balance after Medicare pays is your responsibility. It is our office policy to collect at least 15% of the billed charges at the time of service if you have an HMO as a secondary. This office is required to keep your signature on file authorizing us to file claims to Medicare for you and to release information to that payor if they require it for the proper consideration of a claim. Please read and sign the following statement: I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. Your signature below signifies your understanding and willingness to comply with our payment/financial policy detailed above and authorizes payment of medical benefits to the physician. Patient/Responsible Party Signature: Date: / /

3 Patient Name: Date of Birth: / / Today s Date: / / Authorization to leave messages: I give my permission for the physician(s) and staff of Heidi Goodarzi, M.D., Inc. to leave messages on my telephone answering machine(s) and/or voic (s) noted below regarding my health care, test results, or my appointments. Tel. Number(s): Prescription refill Policy: Please note that most prescription medications require clinical monitoring, therefore medications cannot be refilled over the phone. We require a follow-up visit to determine appropriateness of medication and dosing as well as management of potential side effects to ensure your safety. Release of Medical Information: I authorize the release of medical Information to my primary care physician and/or referring physician, and/or a new referral physician, and to process insurance claims, prescriptions, or to complete any other medical operations as necessary. Patient Authorization for eprescribe: I authorize the physicians and staff of Heidi Goodarzi, M.D., Inc. to enroll me in the eprescribe Program to electronically send an accurate, error-free prescription directly to my pharmacy. Photographs: I authorize the physician(s) and staff of Heidi Goodarzi, M.D., Inc. to photograph me for medicallyrelated documentation purposes. Patient s Responsibility Regarding Laboratory Results: We feel it is very important that you receive all laboratory results including blood work, cultures and pathology results. It is standard procedure for our office to notify our patients by either phone or mail of their results. However, in the unlikely event that a laboratory result is not received by our office, standard procedures for notification of our patients may not take place. We therefore ask our patients to share in the responsibility of obtaining their laboratory results by calling for results if not notified after a reasonable time period. Please Note: You will receive a separate bill from an Outside Laboratory in addition to any bill you may receive from us for services rendered. Should you have any questions regarding Outside Laboratory bills you will need to call them directly at the phone number listed on their statement. New Regulation, Medical Board of California, Mandated by Business and Professions code section 138 Effective June 27, 2010: Dear Patients: Please be informed that I am licensed and regulated by the: Medical Board of California, (800) , Notice of Privacy Practices: By signing this form, you acknowledge that you were informed of the Notice of Privacy Practices of Heidi Goodarzi, M.D., Inc. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our Privacy Officer at I acknowledge being informed of the Notice of Privacy Practices of Heidi Goodarzi, M.D., Inc. Your signature below signifies your understanding and willingness to comply with office policies policy detailed above. Patient/Responsible Party Signature: Date: / /

4 Patient Name: Date of Birth: / / Today s Date: / / Credit Card Policy: This policy is perfectly compatible with all the insurance contracts, as no usual payments are asked for at the time of the visit. We will charge your credit card for co-pays. Also, when the explanation of benefits comes in from your insurance(s) we will then bill you for the balance deemed owed by you, the patient, for any amount up to $100. This will avoid any collection actions or fees to apply to your account. For any charges above $100, we will contact you prior to charging your credit card. This information will be in a secure location and will not be in your chart. Our office will only use this information for collection purposes. We appreciate your understanding and cooperation. MASTERCARD VISA DISCOVER Credit Card Number: Exp. Date: / Signature Code: Name as it appears on the credit card (PLEASE PRINT): Signature of Cardholder Date / / CONSENT TO MEDICAL CARE & TREATMENT OF MINOR CHILDREN I,, the natural parent/legal guardian of, (Please Print LAST, FIRST) (Please Print LAST, FIRST) authorize and consent to medical and surgical care, treatment and procedures to be performed for my child by a licensed physician/provider. In the sole discretion of the attending physician/provider, such care, treatment and procedures are necessary or advisable in the interest of my child s health and well-being. This consent is valid until I have notified Heidi Goodarzi, M.D., Inc. that this policy has been revoked. Patient/Responsible Party Signature: Date: / / FOR OFFICE USE ONLY INABILITY TO OBTAIN ACKNOWLEDGEMENT To be completed only if no signature is obtained. If it is not possible to obtain the individual s acknowledgement, describe the good faith efforts made to obtain the individual s acknowledgement, and the reason why the acknowledgement was not obtained: Signature of provider representative Date / / ( ) Individual refused to sign ( ) Communication barriers prohibited obtaining the acknowledgement ( ) An emergency situation prevented us from obtaining acknowledgement ( ) Other (Please Specify)

5 New Pediatric Patient Clinical Intake Form Appt time: Arrival time: Main reason for Today s visit: Qualities of your condition? Itching/ flaking Pain/tenderness Burning /Blistering Enlarging/ Changing/Darkening No symptoms Other: Severity of your condition? Mild Moderates Severe Duration of your condition? days months years Anything that makes your condition better or worse? Have you used any prescription medication for your condition? Do you have any of the following Symptoms? Cough/Soar Throat Recent illness Is there another skin condition or treatment you would like to discuss today? Past Medical History: (please mark & circle all that apply) Arthritis, Lupus, Autoimmune Disease Diabetes, Thyroid disease Hepatitis B, Hepatitis C, HIV/AIDS Liver Disease, Jaundice, Cirrhosis Blood transfusion, Bone Marrow or Organ Transplant Artificial Joints Anxiety, Depression, Eating Disorder, Psychological problems Drug Abuse, Alcohol Abuse Asthma, Tuberculosis, COPD, Emphysema, Chest Disease Hearing Loss Acid Reflux, (GERD), Stomach Ulcers Kidney Disease, Prostatic Disease Faint Spells, Seizures, Stroke, Neurological Disease Migraines, Headaches, Chronic Pain High or Low Blood pressure, High Cholesterol Anemia, Blood/Bleeding Disease Heart Disease, Pacemaker, Valve Replacement, Atrial Fibrillation, Coronary Artery Disease Breast Cancer, Lung Cancer, Colon Cancer, Prostate Cancer, Leukemia, Lymphoma Radiation Treatment Other Pediatric History: Gestational age at birth (in weeks)? Maternal or Neonatal complications? Meeting Developmental Milestones? Have you had any surgeries in the past? (Please indicate dates): Do you have any history of skin disease? Do you wear Sunscreen? Which Brand(s)? Do you have a family history of Melanoma? (please pay attention that melanoma is a different type of skin cancer than Basal Cell or Squamous Cell Carcinomas) Yes (which relative(s)? No When was your last full skin exam?

6 Appt time: Arrival time: Medications: (Please enter all current medications): Allergies: (Please enter all allergies and the type of reaction you had): Social History: Who does the child live with? Other caregivers? Siblings/Their ages? Do you smoke? Do you drink alcohol? Are you sexually active? Review of Systems: TODAY, are you experiencing any of the following symptoms? Problems with healing or scarring (hypertrophic or keloid) Problems with bleeding Unintentional Weight loss Immunosuppression Joint Aches Headaches Shortness of Breath Chest Pain Abdominal Pain None! SAFETY! To help us provide safe treatments, please mark all that apply to you today: - Pregnancy or planning a pregnancy Yes No - History of MRSA/resistant staphylococcus infection Yes No - History of or exposure to HIV infection Yes No - History of or exposure to Hepatitis B or Hepatitis C Yes No - Allergy to any of the following? Adhesives Lidocaine Topical Antibiotics Bees None - Do you get rapid heart beat with epinephrine (eg. numbing injections at the dentist office)? Yes No - Do you have a Defibrillator, Pacemaker, Artificial heart valve, or Artificial joints placement? Yes No - Are you required to take take antibiotic premedication prior to surgical procedures? Yes No - Are you on any blood thinners? Yes No

Natural Image Skin Center Registration Form

Natural Image Skin Center Registration Form New Patient Name Change Address Change Insurance Change Please present ALL Insurance cards to the receptionist. If patient is a minor, and you are not the legal