SKYPE CONSULTATION DISCLOSURE & CONSENT
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- Silvester Barker
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1 SKYPE CONSULTATION DISCLOSURE & CONSENT Patient Name: Date of Consultation: Skype consultations are offered as a convenience for out of town patients. All paperwork must be completed, signed and returned to our office a minimum of 24 hours prior to your appointment, along with clear photos showing the area of concern (minimum 3 views), a valid photo id and insurance card (if applicable). lourdes@roxburysurgery.com E Fax: (310) During my consultation, I understand that the doctor will evaluate my concerns based upon the information provided in my intake paperwork and the images seen through Skype. I understand that the will be providing general information about possible procedures and that an in person consultation will be necessary prior to making final determinations for surgery. Any price quote provided will be an estimate. I understand that the procedure or procedures discussed may vary once I have been evaluated in person and that applicable fees may vary based upon specifications of the procedure including but not limited to length of procedure and/or required aftercare. A Skype consultation is not a substitute for a medical exam. If you have any urgent concerns, please seek medical attention immediately. No prescriptions can be provided to patients without an in person office evaluation. Patient Signature: Date: Witness Signature: Date:
2 Andrew P. Ordon, M.D., F.A.C.S. Ritu R. Chopra, M.D. Frederick N. Eko, M.D. 465 N. Roxbury Drive, Suite 1001, Beverly Hills, CA Tel: (310) Fax: (310) Highway 111, Suite 300, Rancho Mirage, CA Tel: (760) Fax: (760) Notice of Privacy Practices To our patients This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our commitment to your privacy - Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information. Use and disclosure of your health information in certain special circumstances The following circumstances may require us to use or disclose your health information: 1. To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court or administrative order. 3. If required to do so by a law enforcement officer. 4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat. 5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To a federal official for intelligence and national security activities authorized by law. 7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of law enforcement official. 8. For Workers Compensation and similar programs. Your rights regarding your health information 1. Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests. 2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or healthcare operations. Additionally you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychological notes. You must submit your request in writing to the Surgery Center. 4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to The Surgery Center. You must provide us with a reason that supports your request for amendment. 5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy, contact our front desk receptionist.
3 6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Roxbury Clinic and Surgery Center ( ) or The Plastic Surgery Institute ( ). All complaints must be submitted in writing. You will not be penalized for filing a complaint. 7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for used and disclosures that are not identified by this notice or permitted by applicable law. Notice of Privacy Practices I hereby acknowledge that I have been presented with a copy of Notice of Privacy Practices by Andrew P. Ordon, M.D., Ritu R. Chopra, M.D., Frederick N. Eko, M.D. Name of Patient (Please Print) Signature of Patient Date
4 Andrew P. Ordon, M.D., F.A.C.S. Ritu R. Chopra, M.D. Frederick N. Eko, M.D. 465 N. Roxbury Drive, Suite 1001, Beverly Hills, CA Tel: (310) Fax: (310) Highway 111, Suite 300, Rancho Mirage, CA Tel: (760) Fax: (760) Date: Name: Age: DOB: / / Address: City Zip Home Tel: ( ) Wk Tel: ( ) Cell: ( ) Referring Physician: SS# How did you hear about our Doctor? Have you been to our website? Was our website helpful? No Yes If No, pls. list reason: What is the reason for your visit today? (Circle all applicable procedures below) Nose & Face Breast & Body MediSpa Primary Rhinoplasty Breast Augmentation Botox Revision Rhinoplasty Breast Augmentation with Breast Lift Restylane Brow Lift Breast Reduction Perlane Facelift Capsulectomy Juvéderm Neck Lift Mommy Makeover Radiesse Eyelid Surgery Abdominoplasty Enzyme Peel Facial Implants Post-Bariatric Body Lift Laser Hair Removal Chin Augmentation Brachioplasty (Arm Tuck) Skin Tightening Laser Lip Augmentation Liposuction Photo Facial Lip Suspension Other Pixel Treatment Other Other Cellulite Treatment Other Other Vein Treatment Other Other Other Please describe why you are interested in having the procedure(s) listed above: Have you consulted with other physicians about procedure(s) indicated above: No Yes If Yes, please describe your understanding of the procedure(s) Is this procedure a revision from a previous surgery No Yes If yes, how many previous surgeries? What is your ideal time frame for procedure(s) completion 1of 4
5 Age Weight Height B/P (taken in office) Employer Address Occupation: Marital Status: Primary Insurance Co. Policy # Group # Name of person insured SS# Eligibility Phone # Copay Secondary Insurance Co. Policy # Group # Name of person insured SS# Eligibility Phone # Copay HEALTH INFORMATON Personal Past History: Do you have any chronic medical problems? (Circle all that apply) High Blood Pressure Diabetes Cancer Heart Disease Kidney Disease HIV or AIDS Heart Failure Psychiatric Diagnosis Stroke Seizures Bleeding Problems Hepatitis Heart Attack Liver Disease Emphysema Chest Pain Gastric Reflux Stomach Problems Asthma Other Is there a personal or family history of anesthetic complications? No Yes If yes, please explain Family History: Do you have a family history of any medical problems? (Circle all that apply) Please indicate family member. High Blood Pressure Diabetes Cancer Heart Disease Kidney Disease HIV or AIDS Heart Failure Psychiatric Diagnosis Stroke Seizures Bleeding Problems Hepatitis Heart Attack Liver Disease Emphysema Chest Pain Gastric Reflux Stomach Problems Asthma Other Please list all prior operations: Date List any complications of 4
6 Please list all prior Hospitalizations: Date List any complications Please list ALL medications and/or dietary supplements including: (Prescriptions, Over the Counter Medicines, Aspirin, Vitamins and Herbal Supplements such as Fish Oil, Saw Palmetto, Flax Seed Oil and St. John s Wort) Please list ALL allergies and describe reactions: (i.e. Shellfish, Latex, Penicillin, etc) Social History: Have you ever used tobacco products? No Yes If yes, how long? how much? Which tobacco product(s) have you used? If you are a former smoker, state the year you stopped: Past or current use of Nicotine Gum, Patch, or any other type of stop-smoking aid: No Yes If yes, please list: Alcohol Consumption: Never (Do not consume alcohol) Rare (1-2 drinks a week) Moderate (7-10 drinks a week) Heavy (daily or more than 10 drinks a wk) Did you ever drink heavily in the past? No Yes Are you feeling hopeless about the present/future? No Yes Do you currently have thoughts of harming yourself? No Yes 3of 4
7 Review of Systems: Please answer the following Yes or No questions to the best of your ability. Do you have any of the following conditions, illnesses or symptoms? CARDIOVASCULAR High Blood Pressure Y N Heart Failure Y N Heart Attack Y N Irregular Heartbeat Y N Angina/chest pain Y N Heart Murmur Y N Heart bypass surgery Y N Do you exercise? Y N Pacemaker Y N Comments: NEUROLOGICAL RESPIRATORY Stroke Y N Abnormal Chest X-ray Y N Seizures Y N Asthma Y N Fainting Y N Bronchitis Y N Dizziness Y N Emphysema Y N Headache Y N Recent Chest Infection Y N Double Vision Y N Shortness of Breath Y N Shortness of Breath at night Y N PSYCHIATIC Shortness of Breath on exertion Y N Depression Y N Cough Y N Anxiety Y N Cough with Sputum Y N Psychiatric Care Y N Sleep Apnea Y N Obsessive Compulsive -Use a C-PAP Machine Y N Disorder Y N MUSCULOSKELETAL ENDOCRINE Sciatica Y N Diabetes Y N Herniated disc Y N Thyroid Disease Y N Arthritis Y N Taken Steroids Y N Rheumatoid Y N Neck, Back, Arm,Leg Prob Y N HEMATOLOGIC/ONCOLOGIC/ INFECTIOUS Bleeding Tendency Y N GASTROINTESTINAL Easy Bruising Y N Jaundice Y N Anemia Y N Hepatitis Y N Sickle Cell Disease Y N Ulcers Y N Blood clots in legs Y N Hiatal Hernia Y N Blood clots in lungs Y N Heartburn Y N Radiation Therapy Y N SKIN URINARY/REPRODUCTIVE Basal cell skin cancer Y N Kidney Disease Y N Melanoma Y N Urinary Disease Y N Staph Infection Y N Dialysis Y N If female, could you be preg? Y N EYES Number of live births Cataracts Y N Number of pregnancies Glaucoma Y N Date of last mammogram Date of date of menses (period) ASSIGNMENT AND RELEASE I, the undersigned, have insurance coverage with and assign directly to Andrew P. Ordon, M.D., Ritu R. Chopra, M.D., Dr. Frederick N. Eko, M.D. a Professional Corporation, all Medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. If the nature of the disability be such that it is not covered by insurance, I will be responsible to the doctor for payment of the entire bill. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. Signature of Insured/Guardian Patient s Signature Date Date 4of 4
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Patient Intake Form. Phone: (248) Fax: (248) West Big Beaver Road, Suite 1130 Troy, MI Page 1 of 6.
201 West Big Beaver Road, Suite 1130 Patient Intake Form Last Name: First Name: M.I.: Apt./Suite: City: State: Zip: Home Phone: Cell/Mobile Phone: of Birth: Age: SS#: Email Address: Employer: Occupation:
Name SS# Date of birth / / Gender Ethnicity. Mailing Address City/State ZIP. Marital Status Spouse Name. Phone# Cell# Work#
PATIENT INFORMATION (Please print clearly) Today s date / / Name SS# of birth / / Gender Ethnicity Mailing Address City/State ZIP Marital Status Spouse Name Phone# Cell# Work# EMERGENCY CONTACT PERSON
PATIENT INFORMATION FULL NAME First M.I. Last CONTACT INFORMATION
PATIENT INFORMATION FULL NAME First M.I. Last DATE OF BIRTH SOCIAL SECURITY # M / D / Y AGE: SEX: MALE or FEMALE STREET APT/SUITE #: CITY, STATE, ZIP City State Zip INSURANCE NAME POLICY/MEMBER ID: HOME
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:
Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D
PATIENT REGISTRATION FORM First Name: MI: Last Name: Date of Birth: Address: Apt#: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Work Phone ( ) SS#: - - SEX: Female Male E-mail Address: Ethnicity:
Riverview Orthopedics and Sports Medicine 493 Westfield Rd
Dear New Patient, Riverview Orthopedics and Sports Medicine 493 Westfield Rd Noblesville, IN 46060 (317)-770-4100 (Fax: 317-770-4105) Tipton: 765-675-0030 Thank you for choosing our practice for your orthopedic
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:
PLEASE FILL IN ALL INFORMATION COMPLETELY CITY STATE ZIP HOME PHONE # CELL # DATE OF BIRTH: YOUR EMPLOYER PHONE # HOW DID YOU HEAR ABOUT US?
205-661-2201 3713 Mary Taylor Road Birmingham, AL 35235 Date: PLEASE FILL IN ALL INFORMATION COMPLETELY NAME ADDRESS CITY STATE ZIP HOME PHONE # CELL # WORK # EMAIL DATE OF BIRTH: SEX SELECT ONE: SINGLE
Arizona Retina Associates
PATIENT INFORMATION PLEASE PRINT CLEARLY AND COMPLETE ENTIRE FORM Name FIRST MIDDLE INITIAL LAST SUFFIX (Jr., etc.) Address STREET CITY STATE ZIP Age Birthdate SS# Marital Status S M D W Sex M F Occupation
Signature: Print Name: Date:
~ PLEASE PRINT CLEARLY ~ LAST ADDRESS FIRST MI HOME PHONE SOCIAL SECURITY # EMPLOYER WORK PHONE DATE OF BIRTH JOB/ PROFESSION: CELL PHONE MARITAL STATUS SPOUSE S SPOUSE S SOCIAL SECURITY # (If under spouse
Patient Information TO BE COMPLETED BY PARENT/GUARDIAN ACCIDENT INFORMATION. Date SSN/HIC/Patient ID # Patient Name
1 Date SSN/HIC/Patient ID # Patient Name Address PATIENT INFORMATION Best time/place to contact you? E-mail Sex M F Age Date of Birth Married Widowed Single Separated Divorced Minor Patient Employer/School
Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA Phone: Fax:
Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA 98902 Phone: 453-2010 Fax: 225-6421 Patient Name: Last: First: Middle Initial: Nickname: Sex: M / F Date of Birth:
Medical History Patient Information : Name DOB Age Ht: ft. in Wt: lbs. Gender: Marital Status Procedure(s) you are considering:
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby give my consent for Dr. Marisa Lawrence to use and disclose protected health information (PHI) about me to carry out treatment,
Address: How did you hear about us? Name: Date of Birth: / / Address: City: State: Zip code: Phone Number: HOME - - WORK - - CELL - - EMPLOYER:
Date of Appointment: / / Email Address: How did you hear about us? Have you been seen here before? YES NO If YES, WHEN?: PATIENT INFORMATION Name: Date of Birth: / / AGE: SSN: - - GENDER: Male Female Marital
CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA (360)
CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA 98223-1668 (360) 435-6097 M.C. WHITMAN III, M.D., FACS PETER WOLFF, M.D., FACS DEAR You have been referred to Cascade Surgeons, the office of Dr. Whitman
GARRAMONE PLASTIC SURGERY (239)
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
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:
ROBERT H. OLIVER, M.D., PLLC Otolaryngology Head And Neck Surgery Otolaryngic Allergy Chart #
Chart # PATIENT INFORMATION Please Print, Complete Fully, And Return To The Front Desk Circle One: Mr. Mrs. Ms. Miss. Dr. Child Please Circle: Sex: Male Female Marital Status: S M Other Widowed Patient
PATIENT HISTORY FORM. DOB: Age: Male Female Marital Status. Address: Preferred Method of Contact: Home Cell Work Text
PATIENT HISTORY FORM Name: SSN: (Last) (First) (MI) DOB: Age: Male Female Marital Status Address: (Street) (City) (State) (Zip) Home Phone: Cell: Work: Email Address: Preferred Method of Contact: Home
NOTICE TO OUR PATIENTS
NOTICE TO OUR PATIENTS Although we participate with most insurance plans, you as the patient and/or insured party are responsible for co-pays, deductibles and any non-covered services, which are outlined,
**The Dermatology Clinic sends all appointment reminders via text**
PATIENT INITIAL EVALUATION INFORMATION (Adult) DATE Patient Name Date of Birth / / First Middle Last Month Day Year Mailing Address Street City State Zip Home Phone Work Phone Cell Phone **The Dermatology
PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone
![PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone](/thumbs/78/78629552.jpg "PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone")
PATIENT INFORMATION DATE OF VISIT: Date of Birth Gender: M F PATIENT FULL NAME: Address [Apt. # ] City State Zip Email address: Preferred Phone: Secondary Phone: Circle: Single Married Partnered Divorced
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
375 East Main Street East Islip, NY Welcome!
375 East Main Street East Islip, NY 11730 631-581-5121 www.drforlano.com Welcome! NAME & ADDRESS PATIENT S NAME DATE OF BIRTH WHAT DO YOU PREFER TO BE CALLED? IF PATIENT IS A MINOR, PARENT/GUARDIAN S NAME
William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español
Active feet are happy feet. William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español New Patient Information Form (Please Print) Date: / / Social
Insurance Information:
Name Address Social Security # Date of Birth City State Zip Sex Marital Status Home Phone # Work Phone # Cell# Employer Occupation Race: Employed: Full Time Part Time Retired Student: Full Time Part Time
❶ PATIENT INFORMATION: ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? ❸ RESPONSIBLE PARTY INFORMATION: PATIENT SIGNATURE DATE
❶ PATIENT INFORMATION: DATE WORK PHONE PATIENT S NAME ADDRESS HOME PHONE EMAIL BIRTH DATE AGE CELL PHONE GENDER: MALE FEMALE ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? FAMILY / FRIEND NAME OFFICE
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
Michael A. Bogdan, MD, MBA, FACS
Michael A. Bogdan, MD, MBA, FACS Health History Identification Age Height Weight Please Print your full Name Reason for Consultation Age: Allergies Please check: No Known Drug Allergies No Known Food Allergies
Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:
PATIENT INFORMATION Today s : / / Patient Name (Last, Middle, First) Social Security #: Male / Female: of Birth: / / Street Address: Email Address: Home Phone: Mobile Phone: Work Phone: IF THE PATIENT
Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:
247 River Vista Place Suite 200 Twin Falls, Idaho 83301 www.twinfallssmiles.com (208) 734-8080 PATIENT REGISTRATION Name: Preferred Name: Address: Home Phone: Work Phone: Cell Phone: Email: Can we contact
Northwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR
rthwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR 97035 503-850-4526 DEMOGRAPHCS Last Name: First Name: MI: Date of Birth / / Gender: SS#: