PURPOSE OF VISIT: INTAKE FORM

Transcription

1 BOSTON PLASTIC SURGERY ASSOCIATES BOSTON MEDICAL AESTHETICS DR. BROOKE R. SECKEL DR. SEAN T. DOHERTY JOHN CUMING BUILDING 131 ORNAC SUITE 700 CONCORD, MA PHONE: FAX: DATE: PURPOSE OF VISIT: INTAKE FORM PATIENT CONTACT First Name: Middle Name: Last Name: Street: City: State: Zip Code: Country: Social Security #: Home Phone: Work Phone: Mobile Phone: Preferred Contact: EMERGENCY CONTACT Emergency Contact: _ Relationship: Home Phone: Work Phone: Mobile Phone: First Contact #: PATIENT INFORMATION Date of Birth: Gender: M F Height: Weight: Age: Race: Marital Status:

2 EMPLOYMENT Employment Status: Occupation: _ Company/School: Phone: Street: City: State: Zip Code: HOW DID YOU HEAR ABOUT US? SOCIAL HISTORY Alcohol Drinks/Week: Tobacco Use: I do not use any tobacco I did smoke but quit _ years ago I smoke cigarettes per day I smoke cigars per day I use chewing tobacco I currently use a nicotine patch or gum I live with someone who smokes Web Site Newsletter MEDICAL HISTORY Seminar Physician s Name Patient s Name Other # of Pregnancies: Implant Devices (Defibrillator, Pacemaker): History of Bruising Easily: Are You Right or Left Handed:

3 ALLERGIES Allergies to Medication: Reaction: Allergies: General (i.e.: Latex, Mold, Cats, Food, etc.) CURRENT MEDICATIONS: PRESCRIPTIONS Name: Dosage: Frequency: CURRENT MEDICATIONS: OVER THE COUNTER AND/OR SUPPLEMENTS Name: Dosage: Frequency:

4 RELEVANT MEDICAL HISTORY Never Past Currently Frequency Family History NERVOUS SYSTEM: CARDIAC/HEART: HEMATOLOGICAL/BLOOD: PULMONARY/CHEST: RENAL/URINARY: DIGESTIVE: SKIN: BREAST: CANCER: PAST SURGICAL HISTORY Operation Date Surgeon Complications _

5 MENTAL HEALTH HISTORY PLEASE INITIAL YES OR NO: YES NO Have you previously been involved in counseling? Is there a history of mental health problems in your family? Have you ever been physical abused? Have you ever attempted suicide? Have you been hospitalized for mental health reasons? Is there a history of alcohol or drug problems in your family? Have you ever been treated for depression? Have you ever been treated for a panic disorder? PATIENT SIGNATURE DATE

6 IF YOUR INSURANCE IS RELEVANT TO YOUR VISIT OR CARE AT BOSTON PLASTIC SURGERY ASSOCIATES, PLEASE COMPLETE THE FOLLOWING: INSURED PARTY Relationship: First Name: Middle Name: Last Name: Street: City: State: Zip Code: Employer: Phone: Date of Birth: INSURANCE PROVIDER INFORMATION Provider Name: Primary: Street: City: State: Zip Code: Phone: Contact: Co-Pay: Plan Name: _ Plan Type: _ Gender: M F Insured s ID #: Policy #:

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8 ADDITIONAL INSURANCE INFORMATION Do you need a referral? Do you need assistance in obtaining that information? Yes_ No_ Yes_ No_ I understand I will be responsible for fees incurred if not covered because a referral was not obtained. _ Signature Do you have Medicare or Medicaid? Do you have additional insurance? Date Yes_ No_ Yes_ No_ If yes, what is it? Primary Care Physician

9 BOSTON PLASTIC SURGERY ASSOCIATES PHOTOGRAPH CONSENT I consent to the taking of photographs by Dr. Brooke R. Seckel and/or Dr. Sean T. Doherty or their designee of me or parts of my body in connection with the plastic surgery procedure(s) to be performed by Dr. Brooke R. Seckel and/or Dr. Sean T. Doherty. I further authorize Dr. Brooke R. Seckel and/or Sean T. Doherty or one of their associates to release to the American Society of Plastic Surgeons (ASPS) or any authorized parties such photographs. I provide this authorization as a voluntary contribution in the interests of public education. I understand that such photographs shall become the property of Dr. Brooke R. Seckel and/or Dr. Sean T. Doherty and may be retained by Dr. Brooke R. Seckel and/or Sean T. Doherty or released by Dr. Brooke R. Seckel and/or Sean T. Doherty for the limited purpose of including them in any print, visual or electronic media, specifically including, but not limited to, medical journals and textbooks, for the purpose of informing the medical profession or the general public about plastic surgery procedures and methods. Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the photographs may portray features that will make my identity recognizable. I understand that I may refuse to authorize the release of any health information and that my refusal to consent to the release of health information will prevent the disclosure of such information, but will not affect the health care services I presently receive, or will receive, from Dr. Brooke R. Seckel and/or Sean T. Doherty. I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any times, but if I do so it won t have any effect on any actions taken prior to my revocation. If I do not revoke this authorization, it will expire ten years from the date written below. I understand that the information disclosed, or some portion thereof, may be protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA). I release and discharge Dr. Brooke R. Seckel and/or Sean T. Doherty, and all parties acting under their license and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of the photographs. I certify that I have read the above Authorization and Release and fully understand its terms. Signature _Date