Current Skin Care Product used and Daily Regimen:
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1 Skin Questionnaire/Patient History Last name First Middle Address City State Zip Home ph Cell ph Birth date Date of Visit Emergency Contact (used for our monthly e-newsletter filled with Skin Care Tips, information about Upcoming Events and other Spa Specials and Promotions) How did you hear about Golden Glow? Referral Name Patient History 1. Have you ever taken Accutane? [] YES [] NO When Dosage Months 2. Last use of tretinoin? [] YES [] NO 3. Do you use birth control pills or other forms of hormone therapy? [] YES [] NO 4. Are you pregnant or are you attempting pregnancy? [] YES [] NO 5. Do you have history of shingles/cold sores? [] YES [] NO 6.Are you on [] Valacyclovir [] Zovirax [] Valtrex 7. Are you breastfeeding? [] YES [] NO Any history of Gold therapy in past [] YES [] NO 8. History of skin cancer? [] YES [] NO Type Treatment taken 9. Are you taking any blood thinners? [] YES [] NO 10. Facial Implants? [] YES [] NO 11. History of Seizures? [] YES [] NO 12. Waxing Services within 7-14 Days? [] YES [] NO 13. Irregular, Pigmented moles, warts or growths, unidentified facial growth or mark? [] YES [] NO 14. Keloids, pigmented scars, icepick scars, new scar tissue? [] YES [] NO 15. Pacemaker or other metal implants? [] YES [] NO 16. History of Rosacea, telangiectasia/couperose? [] YES [] NO 17. Acne [] YES [] NO Stage 18. Last use of skin-lightening or bleaching agents Which agent 19. Last exposure to the sun? 20. Any thyroid conditions? [] YES [] NO 21. Allergies to any medications/anesthesia? 22. Any Medical Illness Diabetes HTN Bleeding Problems Heart Problems 23. Are you taking any regular prescription/unprescribed medications? 24. Previous Procedures (please give dates) PEELS LASERS [] Botox [] Light [] Ablative [] Fillers [] Medium [] Non-ablative [] Surgery [] Deep [] Comedome Extraction OTHER TREATMENTS: [] No of facials in last 12 months Areas of your concern [] Lines/wrinkles [] Skin Elasticity [] skin laxity [] Acne Scars [] Skin texture [] Uneven color tone [] Skin pigmentation [] Redness on face [] Skin hydration [] Skin disorder [] Mole changes [] Skin lesion [] Other concerns Current Skin Care Product used and Daily Regimen:
2 Patient Signature Date Take advantage of a Complimentary Skin Analysis today. Follow Up Treatments history Date Treatment Type Any change In Medical history Any new Medicatio ns Last sun exposure/ Tanning Any chances of being pregnant Signature
3 Golden Glow Medical Spa Cancellation Policy As of 5/14/13 Golden Glow Medical Spa will be adjusting its cancellation policy. If you are unable to make your appointment please call at least 24 hours before to cancel as a courtesy to other patients and staff. If you do not call to cancel your appointment before 24 hours or are a no call no show on the day of your appointment you will be charged a $50 FEE for Every Appointment Missed. This courtesy enables us to compensate our employees for their time, and maintains a higher availability of our time for you as well as others. By scheduling an appointment, you are agreeing to our cancellation policy. Patients arriving more than 10 minutes late may result in a shortened appointment or a cancellation if there is not enough time to complete the procedure. If your Appointment is cancelled due to late arrival you will be charged the $50 cancellation fee. Thank you for your understanding and compliance. Golden Glow Medical Spa Management Print Sign Date I have read and understand the cancellation policy
4 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I acknowledge that I have received your Notice of Privacy Practice containing a more complete description of the uses and disclosures of my health insurance information. I understand that the office of Dr. Mira Mahajan has the right to change its Notice of Privacy Practices from time to time. I may contact this office at any time at the below address to obtain a current copy of the Notice of Privacy Practice. I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPPA ), that I have certain rights to privacy regarding the protection of my health information. I understand that this information can and will be used to: Conduct normal healthcare operations such as quality assessments and physician certifications. I understand that I may request in writing that this office restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that this office is not required to agree to my requested restrictions, but once agreed upon, this office is bound to abide by such restrictions. Patient Name (Printed): Signature: Date: OFFICE USE ONLY I attempted to obtain the patient s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below: Date: Initials: Reason:
5 Golden Glow Medical Spa 150 Clearwater/Largo Rd. N Suite 1,Largo, FL *(727) NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability Accountability Act of 1996( HIPPA ) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information. As required by HIPPA, we offer this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposed: treatment, payment and health care operations. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, billing or collection activities, and utilization reviews. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and costumer services. An example would be medical review, legal services and auditing functions. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosers will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to that extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to Dr. Mira Mahajan (Privacy Officer): The right to request restrictions on certain uses and disclosers of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or alternative locations. The right to inspect and copy your protected health information. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice legal duties and privacy practices with respect to protected health information. This notice is effective as of January 1,2011 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, above violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. For more information about HIPPA or to file a complaint.
6 Golden Glow Medical Spa Authorization to Release and Disclose photographs This photographic release pertains to photographs taken during the following treatment: I, (print name), voluntarily consent to the Copyright, publication, and use of my picture and likeness by Golden Glow Medical Spa, affiliates, successors, and assignees. By signing this form, I am allowing Golden Glow Medical Spa, affiliates, successors, and assignee to disclose photographs taken of me before, during, and after treatment. (Please initial either yes or no on each line) For research, educational information purposes: Yes No For publications in a medical journal and /or textbook: Yes No For general advertising, publicity, or promotional purposes: Yes No I understand that the image may be seen by members of the general public. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I hereby release Golden Glow Medical spa from any claim, demand, cause, action, or proceeding of whatever nature arising out of publication and distribution of the said photographs in accordance with the terms of this release. This release also includes affiliates, successors, and assignees of Golden Glow Medical Spa. I also understand that I can revoke (or take away my permission to allow Golden Glow Medical Spa to disclose photographs of me at any time by sending a letter to Golden Glow Medical Spa Medical Director telling him or her not to disclose photographs of me to affiliates, successors, or assignees of Golden Glow Medical Spa. If I send a letter saying that I revoke my authorization, Golden Glow Medical Spa s Medical Director will not disclose any more photographs of me after he or she receives the letter. However, the Medical Director will not need to return any photographs disclosed prior to his or her receipt of the letter. I understand that once my photographs have been disclosed to Golden Glow Medical Spa, affiliates, successors, and assignees the photographs will no longer be protected by federal privacy laws. However, Golden Glow Medical Spa s affiliates, successors, and assignees will not use the photographs except as permitted on this authorization form. I understand that I will be given a signed copy of this form. I hereby release Golden Glow Medical Spa, its affiliates, successors, and assignees from any claim demand, cause, action, or proceeding of whatever nature arising out of publication and distribution of the said photographs in accordance with the terms of this authorization. Print Name: Signature: Date:
7 Financial Responsibilities The following procedures/surgeries: Fractional CO2, Thermitight, Liposuction, and Facial fat transfer, require specific payment criteria in regards to booking and cancellations. The total includes fees charged by your doctor, the cost of the surgical supplies, anesthesia, and operating room reservation for the day of the procedure/surgery. Mahajan Cosmetic Center and Golden Glow Medical Spa DO NOT accept any type of insurance, so you will be responsible for full payment of your procedure/surgery. The fees charged for this procedure do NOT include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome results of your surgery. In signing the consent for this surgery/procedure, you acknowledge that you have been informed about its risk and consequences and accept responsibility for the facility decisions that were made along with the financial costs of all future treatments. I understand that with cosmetic surgery, I am responsible for full surgical fee(s) quoted to me. I understand when scheduling any of the above procedures/surgery a deposit of 50% must be made. I understand that there will be a non-refundable fee for booking and scheduling this procedure/surgery of 10% of total cost of the procedure/surgery, which is a part of the overall surgical fee. Should you cancel your surgery without an approved medically acceptable reason, submitted in writing and acceptable to the practice, within 1 week of your scheduled surgery, this fee is forfeited. While this may appear to be charged for service(s) which were not provided, this fee is necessary to reserve time in the OR, doctor s time availability and in the practice, which are done when you schedule. I understand and unconditionally and irrevocably accept the financial responsibilities as outlined above Patient s Name Date Signature
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7521 Virginia Oaks Drive #240 Gainesville, VA 20155 Ph: 703-753-7600 PATIENT NAME (FIRST, MIDDLE, LAST) PATIENT REGISTRATION DATE: HOME PHONE HOME ADDRESS CELL PHONE CITY STATE ZIP CODE SOCIAL SECURITY
Patient Information (Please Print)
Page 1 Patient Information (Please Print) Patient s Name: Last First Middle Birthdate: / / SSN: Gender: Male Female Race: Ethnicity: Preferred Language: Marital Status: Single Married Other: Spouse s Name:
Insurance Form. Patient Name: Date Last First Middle
Insurance Form Patient Name: Last First Middle Social Security Number Primary Insurance Carrier Insured Name & of Birth Relationship Member Identification Number Group Number Do you have Medical Insurance?
New Patient Registration Packet
New Patient Registration Packet This Patient Registration Packet includes the following: 1. Patient Registration Sheet (page 1) This form is for patient demographic and physician referral information.
APPLETON PLASTIC SURGERY CENTER, S. C. (920)
APPLETON PLASTIC SURGERY CENTER, S. C. (920)738-7200 Please print legibly and fill in or correct all fields. Patient Name Parent/Legal Guardian Name Address Last First Middle Last First Middle Street &
Informed Consent for Physical Therapy Services
Informed Consent for Physical Therapy Services The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative
ELYSE S. RAFAL, F.A.A.D.
ELYSE S. RAFAL, F.A.A.D. Welcome to our practice. Thank you for placing your trust in us. We look forward to serving you with quality and compassionate care. Patient Information Today s : First Name: M.I.
West Coast Plastic Surgery Center, Inc.
West Coast Plastic Surgery Center, Inc. Today s : Yuly Gorodisky, D.O. Plastic and Reconstructive Surgeon 32144 Agoura Road, Suite 220 Westlake Village, CA 91361 (818) 879-0100 Patient s Name: of Birth:
Name: First MI Last. Birthdate: / / Age: Social Security #:
Today s Date: Patient Information Name: First MI Last Male Female Single Married Divorced Widowed Separated Birthdate: / / Age: Social Security #: Home Address: City: State: Zip: Home Phone: Cell: E-mail:
Laguna Woods Dermatology
Laguna Woods Dermatology Patient Registration Form Visit date: Name: First Middle Last of Birth: Social Security Number: Nickname (optional): Sex: M F Address: Street City State Zip Mr. Mrs. Dr. Home Phone:
DIABLO DERMATOLOGY 3436 Hillcrest Ave., Suite 150, Antioch, CA (925) MEDICAL HISTORY
Patient Name: DIABLO DERMATOLOGY 3436 Hillcrest Ave., Suite 150, Antioch, CA 94531 (925) 754-6767 MEDICAL HISTORY Date: Referred by: Self Family/Friend Doctor Doctor s Name: 1. Are you aware of being allergic
Street Address Apt. No. City State Zip. Race: Ethnicity: Hispanic Not Hispanic or Latino. Marital Status: Single Married Widowed Divorced
Patient Information MRN# Patient Name: Address: Street Address Apt. No. City State Zip Age: Birthdate: *Social Security: Phone:Home# Work # Cell # Gender: Male Female Primary Language: Race: Ethnicity:
PLEASE. To make your check-in process as smooth and fast as possible: DO NOT DATE THE FORMS BEFORE ARRIVING TO THE OFFICE
PLEASE To make your check-in process as smooth and fast as possible: WRITE LEGIBLY (PRINT) FILL ALL FORMS COMPLETELY DO NOT DATE THE FORMS BEFORE ARRIVING TO THE OFFICE BECAUSE WE WILL SCAN THESE FORMS
Date: First Name: MI: Date of Birth: / / Last Name: Social Security Number: / / Preferred Name: Sex: Gender: Marital Status: Single Married Other
PATIENT INFORMATION Date: First Name: MI: Date of Birth: / / Last Name: Social Security Number: / / Preferred Name: Sex: Gender: Home Address: City: State: Zip Code: Marital Status: Single Married Other
Patient name: LAST FIRST MIDDLE. Address: Responsible Party SS#: Required If patient a minor and/or full-time student. Employer: Occupation:
PATIENT Information SHEET ACCT # PT Patient name: LAST FIRST MIDDLE Date of Birth: Age: (please circle :) Female Male Address: Responsible Party SS#: Required If patient a minor and/or full-time student
PATIENT INFORMATION. (Please complete all sections) NAME OF PARENT(S) OR GUARDIAN(S): PARENT, SPOUSE, OR RESPONSIBLE PARTY If Different from Patient
Date: PATIENT INFORMATION (Please complete all sections) Office Location: PATIENT NAME (Last, First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
No Show / Cancellation Policy
Patient Name: Date of Birth: Email: Home Phone: Cell Phone: SSN: Home Address: City State Zip Sex : Male/Female/In-Transition Marital Status: Single/Married/Divorced/Widow(er) Employer Name: Occupation:
Welcome! 7000 W. Plano Parkway Plano, TX Please remember to bring: New Patient Paperwork. Current Insurance Card
7000 W. Plano Parkway Plano, TX 75093 SW corner of Plano Pkwy & Marsh Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of
Grekin Skin Institute
Grekin Skin Institute About Financial Arrangements We are committed to providing you with the best possible care. If you have medical insurance we are anxious to help you receive your maximum allowable
PATIENT INFORMATION. Patient s Name Last First Middle Married Single Divorced Widowed. Address Street City State Zip
PATIENT INFORMATION Date Patient s Name Last First Middle Married Single Divorced Widowed Address Street City State Zip Birth Date // Age _ Sex (M/F) _ Driver s License # Social Security # Home Phone (
PATIENT REGISTRATION Date. INSURANCE & BILLING INFORMATION Payment Required At Time of Service Unless Prior Arrangements Have Been Made
PATIENT REGISTRATION Date Name Marital Status Date of Age S/M/W/D/SEP Birth Patient Social Security # Primary Language Race & Ethnicity Street Address City, State, ZIP_ Phone (Home) (Work) Occupation/
PATIENT INFORMATION EMERGENCY CONTACT
Phone (614) 682-5095 Fax: (614) 891-6533 www.ohioplasticsurgeryspecialists.com PATIENT INFORMATION Name Birth Date Age (First, Middle Initial, Last) Address City State Zip Home Phone ( ) Work Phone ( )
New Patient Information Form
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McDonnell Dermatology, LLC Olympia Ave Suite 204 Punta Gorda, FL Phone Fax Patient Care Policy Letter
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Patient Registration Form
Patient Registration Form Please bring insurance card and photo ID to your appointment Patient Name of Birth Today s Address City State Zip Home Phone Cell # Work # Circle your contact preference: Home
Dear Patient: Welcome and thank you for choosing our practice.
Dear Patient: Welcome and thank you for choosing our practice. Please bring the following with you to your appointment: Your completed forms, along with your current insurance card, photo identification
Would you like to receive s with special offers from Carolina Vein Center? yes no
Carolina Vein Center Patient Information Name: Date: Address: Home Phone: City: State: Zip: Work Phone: SS#: Marital Status: Occupation: Date of Birth: _ Cell Phone: Emergency Contact: E-Mail: Emergency