Thank you for joining us at The Center for Medical Weight Loss! We are glad you are here!
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- Millicent Wright
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1 JODIE REINERTSON, MD Thank you for joining us at The Center for Medical Weight Loss! We are glad you are here! Internet : ~ Please check the FIRST way in which you heard about us ~ Google.com Citysearch.com Yelp.com Yahoo.com Dermsnextdoor.com Bing.com Latisse.com Radiesse.com Sculptra Aesthetic website Thermage.com Isolaz Therapy Stop the Pop Website Facebook The Center for Medical Weight Loss Website Magazine/Newspaper : Seattle Metropolitan Magazine Seattle Magazine Friends of CosMedic Skincare : Dress for Success Dr. Daniel McKay, DDS Other : (please specify below) Friend: Relative: UW Daily Newspaper _ Cabrini Medical Tower
2 PATIENT INFORMATION: PATIENT NAME : DATE OF BIRTH: ADDRESS: CITY & STATE: ZIP CODE: PREFERRED CONTACT NUMBER: SECONDARY CONTACT NUMBER: 3 RD CONTACT NUMBER: EMPLOYER: PARTNER/SPOUSE NAME: ADDRESS: Your address will only be used for in-office communication and will not be sold or given to any 3 rd party individual or organization. PLEASE CHECK HERE IF YOU WOULD LIKE TO JOIN OUR PATIENT RECOGNITION PROGRAM. NEWSLETTER IS SENT ONCE A MONTH RESPONSIBLE PARTY (Required for Minors): NAME: RELATION: ADDRESS, CITY, STATE, ZIP: CONTACT NUMBER: IN CASE OF EMERGENCY, PLEASE NOTIFY: NAME: RELATION: HOME PHONE: WORK PHONE: CELL PHONE: FINANCIAL RESPONSIBILITY AGREEMENT We are not contracted with any insurance company; however, we can provide a superbill to submit to your insurance company for reimbursement. Ultimately, you will assume full financial responsibility. Payment is due at the time of service. We accept payment in the form of cash, AMEX, Visa, MasterCard & Discover. Payment plans are available through third party financing groups. NO SHOWS may be subjected to a fee of $50 if appointment is not cancelled at least 24 hours in advance. A deposit must be taken for major procedures. Sculptra Aesthetic procedures require a $250 deposit. I further understand that providing proof of my insurance plan(s) or explanation of benefits does not hold CosMedic Skincare responsible for verifying this information. I accept full financial responsibility for medical expenses incurred at the CosMedic Skincare for all services provided. In the event where it is necessary to refer my account to an attorney for collection, I am responsible for all fees and expenses. Signature (If under 18, must be signed by parent/guardian) / / Date If parent/guardian, print name [ Optional ] Procedures or products of interest to you (please check all that apply) Dermal Filler for accentuating facial features and correcting folds and wrinkles (Juvederm, Radiesse, and Sculptra) BOTOX for Wrinkles Sclerotherapy for Spider Veins BOTOX for Excessive Sweating Melanage Peel for Melasma Laser Lipo for Body Sculpting Laser Hair Removal Thermage for Skin Tightening Skin Resurfacing with DOT Therapy Laser/Light Treatments for Treating Pigment and/or Age Spots Eyebrow Waxing or Tinting HydraFacial MD to Promote Smooth, Healthy Skin Chemical Peels Microdermabrasion Medical-Grade Skincare Medical Weight Loss Program Permanent Make-up Sculptra Aesthetic for Collagen Production Other, Please Specify:
3 PATIENT MEDICAL INFORMATION Primary Physician: Hospital/Clinic: Last Physical: Last Blood Work: Drug Allergies: Food Allergies: List of Medications Currently Taking: Past Medical History: Past Surgical History: Family Medical History: Women Menstrual Cycle is Regular or Irregular #of Children: On Birth Control Planning Children Pregnant Nursing ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have received a copy of the Notice of Privacy Practices. The Notice describes how my health information may be used or disclosed by CosMedic Skincare and the Center for Medical Weight Loss. I understand that I should read it carefully. I am aware that the Notice may be changed at any time. I may obtain a revised copy of the Notice by calling or by requesting one at this office. / / Date Print Name Signature
4 WEIGHT CONTROL QUESTIONNAIRE This form has been designed to assist you in organizing your thoughts regarding what you want to achieve with your customized weight loss program. By first filling out this questionnaire as completely as possible, and then reviewing it with Dr. Reinertson, you will learn what goals are reasonably attainable. How much weight do you expect to lose? Each week? Each month? What will happen if you don t lose that much weight or do not lose it quickly? How will you react? Do you understand the difference between fat loss and water loss? What size clothes do you expect to be able to wear when you reach your goal weight? What do you expect from us (your medical counselors)? Be specific: Will it change your life in any way (for better or worse) when you reach your goal weight? Do you expect to be doing anything you are not doing now? (Describe in detail) Do you expect to STOP doing something you ARE DOING NOW? (Describe in detail) Will you be able to handle compliments about how you look when you are at your goal weight? Will the new you pose a threat to any relationships? (Please specify) How will family and friends respond to the new you? Do you expect to get a better job? Will you get more respect from other people? (Who specifically) Will you feel comfortable with these altered responses from others? Will you be expected to perform better at work (or at home)? Will you have to be more sociable than you are now? Will you have to assume any new responsibilities? (Please describe) What will happen if some of your expectations don t come true? What might you do? What do you expect to have to do to maintain your goal weight? Will you continue to watch your food intake? Continue with professional medical monitoring? Exercise? For how long? Do you have any other expectations than those listed above? If so, what are they? Please describe them in detail: Patient Name: Date: / /
5 Appointment Cancellation Policy In an effort to provide the best service possible for all of our patients, we have the following cancellation policy for all appointments: We request 24-hour notice if you wish to cancel or reschedule your appointment. If you are booked for a major procedure, we request 72-hour notice. This enables us to respond to the higher demand over availability for appointments. Patients who cancel or reschedule in less than the required time, or do not show for their scheduled appointments, will be charged a $50 fee since we were unable to offer that time to another patient. Patients will either be charged the fee at their next visit or in special circumstances, they will be required to pay a $50 deposit to secure a future appointment. The cancellation fee is non-refundable, non-transferrable, and due in full at the subsequent treatment date. By signing below I agree that I was informed of this policy and I understand it. X Print Name Date: / /
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 (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:
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 (
PLASTIC & RECONSTRUCTIVE SURGERY, P.C.
PLASTIC & RECONSTRUCTIVE SURGERY, P.C. NAME: DATE OF BIRTH: AGE: ADDRESS: HOME WORK: CELL: EMAIL: SS#: PATIENT EMPLOYER: EMPLOYER ADDRESS: SPOUSE OR PARENT NAME: REFERRING PHYSICIAN: NEXT OF KIN OR EMERGENCY
Membership Agreement
Membership Agreement Name Date Street Address City State Zip Code Home phone Cell Phone Email ---------------------------------------------------------------------------------------------------------------------
Cosmetic Interest Questionnaire
Long Ridge Dermatology 1051 Long Ridge Road, Stamford, CT 06903 Tel: 203-329-7960 Fax: 203-329-7920 info@longridgedermatology.com Cosmetic Interest Questionnaire For many people, changes in physical appearance
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made.
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made. Name: Jr. Sr. Last First Middle Prefer to be called: Married Single Date of Birth / / Patient
Patient Registration Form
I Patient Registration Form Please Print Clearly and Fill in All the Blanks PATIENT INFORMATION First Name: Middle Initial: Last Name: DOB: Age Address: Apt #: City: State: Zip: SSN: Driver License Number:
GREGORY J. STAGNONE, M.D., P.A LBJ Frwy, Ste. 500 Dallas, TX 75240
: Last Name: _ GREGORY J. STAGNONE, M.D., P.A. 6190 LBJ Frwy, Ste. 500 Dallas, TX 75240 First: Middle: of Birth: / / Age: Social Security # - - Address: City State: Zip Home: ( ) Cell: ( ) Other: ( ) **Any
MEDICAL HISTORY. May we send you including news and specials about the practice? Yes No May we request you on facebook?
MEDICAL HISTORY ABOUT DR. DAVID RANKIN- Cosmetic and reconstructive surgery is where art and science blend to combine intuition, creativity and artistic sense with extensive surgical training, discipline
PATIENT UPDATE FORM. In an effort to have the most up to date information, we ask that this form be completed annually.
PATIENT UPDATE FORM In an effort to have the most up to date information, we ask that this form be completed annually. DATE: CHART: Social Security Number Date of Birth NAME First, Middle, Last MAILING
Amy Wechsler, MD. Dermatology. Welcome To Our Office!
Welcome To Our Office! 1. Your appointment time is reserved for you. If you must reschedule an appointment, please try to do so in a timely fashion so that another patient may be accommodated and you can
Patient Information *Please Complete All Sections*
Front Desk Check-In Initials Patient Information *Please Complete All Sections* Account # (Office Use Only) Name (First, MI, Last) Date of Birth / / Age: Sex: M F Mailing Address Apt # City State Zip Home
INSURANCE INFORMATION
PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:
Current Skin Care Product used and Daily Regimen:
Skin Questionnaire/Patient History Last name First Middle Address City State Zip Home ph Cell ph Birth date Date of Visit Emergency Contact Email (used for our monthly e-newsletter filled with Skin Care
We collect all applicable copayments/coinsurance and deductibles at time of service. We accept cash, checks, Visa, MasterCard, and Discover.
DeVore Dermatology, P.A. KAREN A. DEVORE, M.D. TEL: (864) 596-7546 490 FLOYD ROAD FAX: (864) 596-7549 SPARTANBURG, SC 29307 www.devoredermatology.com Dear Friends and Patients: Thank you for choosing DeVore
Get Serious About Your Skin
PATIENT INFORMATION: Today s Date First Name Last Name Middle Address Apt. City State Zip E-Mail Address Home Phone ( ) Work Phone ( ) Cell Phone ( ) Date of Birth Age Social Security Number Sex: o M o
YOUR APPOINTMENT IS SCHEDULED FOR:
JEFFREY J. HELLER, D.O., F.A.A.D. 511 N. CLYDE MORRIS BLVD. DAYTONA BEACH, FL 32114 OR 790 DUNLAWTON AVE., SUITE H ADULT PORT ORANGE, FL 32127 (TO HANDOUT, FAX, PHONE (386) 239-8700 MAIL, OR E-MAIL) FAX
Name: LAST FIRST MIDDLE INITIAL. Address: City: State: Zip: SSN: DOB: Age: Home Phone: Work Phone: Cell Phone: Occupation:
Today s Date: Name: LAST FIRST MIDDLE INITIAL City: State: Zip: SSN: DOB: Age: Home Phone: Work Phone: Cell Phone: Occupation: Mailing Address (if different): City: State: Zip: Primary Care Physician:
California Vein Specialists
Name: Birthdate: Address: City: State: Zip: Home Phone: ( ) Okay to leave message with details Do not leave detailed message Cell Phone: ( ) Okay to leave message with details Do not leave detailed message
Patient Information. Patient Medical Insurance
Patient Name: Referring Physician: Birth Date: Primary Care Physician: Patient ID# +++++ Make corrections on form and alert staff for any pre-filled information that is incorrect +++++ Patient Information
PROFESSIONAL AND GENERAL LIABILITY APPLICATION FOR MEDICAL SPAS. 1. Name of Applicant: 2. Mailing Address:
PROFESSIONAL AND GENERAL LIABILITY APPLICATION FOR MEDICAL SPAS 1. Name of Applicant: 2. Mailing Address: 3. Location Address: (If multiple name and locations, please attach list) 4. Telephone Number:
MEDICAL SPA PROFESSIONAL LIABILITY INSURANCE APPLICATION (CLAIMS MADE)
MEDICAL SPA PROFESSIONAL LIABILITY INSURANCE APPLICATION (CLAIMS MADE) 1. Full Name of Applicant: (Include all DBA's and subsidiaries seeking coverage under the policy for which you are applying.) 2. Mailing
Patient Information. Patient Medical Insurance
Patient Name: Referring Physician: Birth Date: Primary Care Physician: Patient ID# +++++ Make corrections on form and alert staff for any pre-filled information that is incorrect +++++ Patient Information
GWINNETT DERMATOLOGY, P.C. PATIENT REGISTRATION
PATIENT INFORMATION (PLEASE PRINT LEGIBLY) GWINNETT DERMATOLOGY, P.C. PATIENT REGISTRATION LAST NAME FIRST NAME, MI PREFERRED NAME DATE OF BIRTH GENDER Male Female STREET ADDRESS CITY, STATE, ZIP CODE
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
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Today s Date: Reason for Visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip: Secondary (Out of State) Address: City/State/Zip: Pharmacy Phone: City: Cross Streets:
Wilmington Dermatology Center Patient History Form
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PATIENT HISTORY QUESTIONNAIRE
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PATIENT MEDICAL HISTORY
PATIENT MEDICAL HISTORY Last Name First Name Please describe your skin condition (including location, duration and symptoms): Is this a new or chronic condition? LIST ALL MEDICAL/HEALTH PROBLEMS (including
PHARMACY INFORMATION
NAAMAN CLINIC TODAY S DATE: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name Address: First Middle Last Street & Apt # City State Zip SS# Birthdate Age: Sex: Female Male Marital Status: Single
Patient Information Patient Info. Update
Medical History Brian R. Carr, D.D.S., M.D Patient Information Gagandeep Pandher,D.D.S. Patient Info. Update Date Date Initials Date Initials Name Address Cell Phone # City State Zip Work # Date of Birth
Thomas Dermatology General and Pediatric Dermatology MOHS Surgery and Cosmetic Dermatology
To Our Valued Patients: Thomas Dermatology We apologize in advance for the increased paper work, specifically the bubble sheets, you are required to fill out. As mandated by the Federal Government, we
New Patient Name Change Address Change General Update Today s Date / / Name: Date of Birth: / / SS# Gender: Male Female.
Please fill out with Blue or Black Ink PATIENT INFORMATION: Name: New Patient Name Change Address Change General Update Today s Date / / Last First M.I. Nickname Previous Name Date of Birth: / / SS# Gender:
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:
Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight:
NEW PATIENT HISTORY Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight: How did you hear about us? Insurance physician friend other Primary care physician: Name City Phone Referring
Arizona Center for Aesthetic Plastic Surgery Steven H. Turkeltaub, M.D., P.C. Certified, American Board of Plastic Surgery
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Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight:
NEW PATIENT HISTOR Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight: How did you hear about us? Insurance Physician Friend Other Primary care physician: Name City Phone Referring
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PATIENT INFORMATION. Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:
PATIENT INTAKE FORM (Please Print or Type. Once complete, either fax to 949-553-3561, email to Stacie@thephysiofix.com or bring with you during your first session!) Today s date: PATIENT INFORMATION Patient
PATIENT REGISTRATION INFORMATION Initial
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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:
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Current symptoms, conditions, and complaints:
Medical History Form Name: : Have you RECENTLY noted any of the following (check all that apply)? Changes in bowel or bladder function Weight loss/gain Fever/chills/sweats Shortness of breath Severe constant
Policies and information:
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Arizona Center for Aesthetic Plastic Surgery Steven H. Turkeltaub, M.D., P.C. Certified, American Board of Plastic Surgery
Date Referred By: Patient Last Name First M.I. Sex Marital Date of Birth Age Status Present Mailing Address - Street City State Zip Social Security # Home Telephone # Cell phone # Business Telephone #
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PATIENT SIGNATURE: DATE:
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PATIENT APPLICATION FORM
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Felix Linetsky, M.D. 611 Druid Road East, Suite 303 ~ Clearwater, Florida ~ (727) ~ Fax (727)
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Singh Family Dental Dr. P. Singh, PLLC
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