GREGORY J. STAGNONE, M.D., P.A LBJ Frwy, Ste. 500 Dallas, TX 75240
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1 : Last Name: _ GREGORY J. STAGNONE, M.D., P.A LBJ Frwy, Ste. 500 Dallas, TX First: Middle: of Birth: / / Age: Social Security # - - Address: City State: Zip Home: ( ) Cell: ( ) Other: ( ) **Any other # you may be reached at the day of surgery for last minute changes **Pharmacy Telephone Number Address Would you like to receive apt. confirmation via , Text message, or Both? address: Occupation: Employer: Work # : ( ) Address: City State: Zip Marital Status: Single Married Other Spouse s Name: (or parent, if patient is a minor) Spouse s of Birth: / / Spouse s Employer: Spouse s Cell # : ( ) Spouse s Work #: ( ) Emergency Contact Information - Name: Relationship: Address: Home: ( ) Cell:( ) Work : ( ) How Did You Hear About Our Office? Patient D Magazine Websearch Top-Ten MD Sign/Drove By Personal Doctor Real Self Other Please tell us what you are here to discuss. Would you like information on any of our other services? Surgery Injectables & Lasers Skin Therapies Eyelids or Browlift Botox Acne Nose Reshaping Fillers (Juvederm) Facial Discoloration Neck, Chin Contouring Laser Hair Removal Facial Skin Retexturizing Breast Implants Laser Skin Tightening Lip Enhancement Breast Lift or Reduction Laser Wrinkle Removal Eyelash Enhancement Tummy Tuck Laser Correction of Skin Permanent Makeup Labial Reshaping Discoloration Eyebrows Eyeliner Liposuction, Body Contouring Laser for Spider Vein Lips Scar Camouflage Other Areas Correction of Eyelid Bags Enzyme Therapy (smoothing) Lip Enhancement Eye Rejuvenation
2 HISTORY & PHYSICAL NAME: _ SOCIAL HISTORY Age: Sex: M F Weight: Height: Married: Y N Occupation: : Do You Have a Responsible Adult Available to Assist During Recovery Period Y N Relationship: HABITS Smoke: Y N Amount: Alcohol: Y N Amount: Drug Allergies: Y N List drug(s) and type of reaction: Latex Allergy: Y N Tape Allergy: Y N Anesthesia Allergy: Y N MEDICATIONS: List dose or number of pills per day Prescription Drugs Non-Prescription (Vitamins; Herbs) Regular Aspirin Use: Y N Dosage & Frequency: NSA (Advil, Motrin, Ibuprofen): Y N Dosage & Frequency: FAMILY HISTORY: Have any blood relatives ever had the following problems: Abnormal Bleeding: Y N Abnormal Clotting: Y N Anesthetic Problems: Y N Cancer: Y N Blood Clots in Legs: Y N Please describe questions with a Yes answer: PERSONAL PAST HISTORY: Have you ever had: Abnormal Bleeding:Y N Asthma: Y N HIV Y N Abnormal Clotting: Y N Diabetes: Y N Hypertension: Y N Anemia: Y N Heart Attack: Y N Weight change in past 12 Mo.: Y N Angina: Y N Hepatitis: Y N Other Serious Illness: Y N Please describe questions with a Yes answer: Have you ever received a transfusion? Y N If yes, what year? Have you been tested for HIV? Y N If yes, what year Test results: Positive Negative Do you wear: Contact lenses: Y N Dentures: Y N Crowns/Veneers/Caps/Bonding: Y N List all previous surgeries and any complications: last seen by Primary Care Physician: Primary Care Physician (name) (telephone) ( ) (address) FEMALE PATIENTS ONLY: Number of pregnancies Number of children Last menstrual period Have you had a tubal ligation or hysterectomy? Y N If yes, when?
3 GREGORY J. STAGNONE, M.D., P.A LBJ Frwy, Ste. 500 Dallas, TX PLASTIC SURGERY CENTER OF DALLAS FINANCIAL ARRANGMENTS AND OFFICE POLICIES We are committed to providing you with the best possible care. The following is a statement of our financial policies which we request that you read and acknowledge prior to any treatment. Scheduling and Cancellation Policy Full payment for cosmetic procedures is due two weeks prior to surgery or at time of scheduling. To reserve a surgical date, a deposit of $2, is required (or $2000 by check or cash). We accept payment by cash, cashier s check, Care Credit financing or major credit cards. After your surgery is scheduled, there will be a separate pre-operative appointment to thoroughly review the details of your surgery, obtain prescriptions, sign consent forms and complete all arrangements. Your balance is due in FULL at your pre-op appointment. If surgery is cancelled at any time following your pre-operative appointment, there will be an administrative fee of $ deducted from your refund, in addition to any expenses we have incurred such as lab fees, shipping charges, financial transaction fees, etc. If surgery is cancelled within five working days of your procedure, 50% of your quoted fee will be refunded. Failure to show up for your scheduled surgery will result in forfeiture of 100% of your fees. We very much understand that personal emergencies may come up unexpectedly, requiring that your surgery be rescheduled. These will be addressed individually but we may allow the above penalties to be applied towards rescheduled surgery one time. Multiple cancellations resulting in unfilled time are very costly to us. Therefore, if rescheduling is requested a second time there will be a 15% surcharge penalty which must be prepaid. All fees will be 100% forfeited in the event of a third cancellation. Forfeited funds will not be applied to future procedures. When using a finance company such as Care Credit, after your loan has been funded, any refunds will be based on their rules and policies in addition to those described above. In the event of a dispute over payments or refunds with a credit card company or any other financial entity, we may have to disclose certain medical information to aid in resolution. For this reason, we require a HIPPA waiver for the use of credit. With your signature you hereby agree to waive your right to privacy under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) guidelines only so that we may disclose whatever medical information is necessary to aid in the resolution of any such dispute. Revisions or Complications If there are necessary revisions to surgery, there will be no surgeon s fee. However, you would be responsible for anesthesia and operating room charges. This revision policy is confined to the 6 week period following your surgery unless other arrangements are made in advance of 6 weeks time. This policy does not apply to laser treatments or liposuction. (Please discuss these with the doctor.)
4 GREGORY J. STAGNONE, M.D., P.A LBJ Frwy, Ste. 500 Dallas, TX Short Term Disability, Health Insurance & FMLA Paperwork Policy If you are filing FMLA paperwork and/or Short Term Disability with your employer, please complete all paperwork prior to your pre-operative visit and bring it with you to your pre-op appointment. We are not staffed to complete these lengthy documents or forms and have not factored into our fees the time necessary to complete them. Forms which you have completed will be given to Dr. Stagnone to sign and will be returned to you on the day of surgery. The Plastic Surgery Center of Dallas is a non-insurance facility, specializing only in elective aesthetic surgery. Filing health insurance claims requires insurance coding software and up to date code books that we do not have at this facility. We do not have insurance or billing staff and we do not complete and/or file any insurance paperwork. We will give you any information we have and/or records however, so that you may file for insurance benefits on your own behalf. For any exceptions to this policy, you would be billed as an additional service. I fully understand the Plastic Surgery Center of Dallas policy as described above. Photography Medical photography is essential for legal documentation of your pre-operative condition and for planning of cosmetic surgery as well as medical education. I consent to photography of appropriate portions of my face or body in preparation for surgery and for postoperative follow up. I consent to the use of my photos for patient education or other educational or promotional purposes, providing that my identity is not revealed. Medical Photos By signing this consent, I understand the photos taken before & after my surgery are for the purpose of chart documentation and are a part of my legal medical record. I fully understand photos will NOT be released, copied, ed, or mailed to me. I acknowledge that I am responsible for taking my own before & after photos if I so choose. Patient Signature
5 Plastic Surgery Center Of Dallas Acknowledgement of Receipt of Notice of Privacy Practices Print Name of Patient Signature of Patient If Patient is a minor: Signature of patient Representative (Required if patient is a minor) Relationship of Patient Representative to Patient Please note that Sate and Federal Law provides additional protections for minors and restricts the release of certain patient information to anyone other than the minor patient. Secure Phone Option: Is there a phone number where a message containing personal health information could be left in the event you are not available when we call? YES NO If Yes, what is the number? Please list any persons you would like to authorize to have access to your billing, appointments, or health information*. Such as your spouse, caretaker, or other family member: NAME _ RELATIONSHIP *With the exculsion of information that is protected under State and Federal Law.
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:
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Local Address: City State Zip. Permanent Address: City State Zip. Secondary Insurance Co: Insurance Phone: Policy #:
Patient Intake Form : Patient Name: (Last) (First) (M) Local Address: City State Zip Permanent Address: City State Zip Home Phone: Work Phone: Cell Phone: Birthdate: Age: Sex: M F Marital Status: Ethnicity:
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Referred By: Patient Last Name First M.I. Sex Marital of Birth Age Status Present Mailing Address - Street City State Zip Social Security # Home Telephone # Cell phone # Business Telephone # E-mail address
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 #
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
Amy Wechsler, MD. Dermatology. Welcome To Our Office!
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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:
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Whom May We Thank for Referring You? Primary Care Physician. Insured/Responsible Party. Patient Information. Patient s Spouse/Guardian
Whom May We Thank for Referring You? Name: Other: Newspaper Radio TV Seminar Staff Yellow Pages Other Primary Care Physician Name: Address:_ City: State: Zip: Phone: Insured/Responsible Party Patient Information
Statement of Financial Responsibility
: Patient Intake Form Patient Name: (Last) (First) (M): Cell Phone Home Phone Work Phone Mailing Address: City: State: Zip: Home Address: City: State: Zip: (If Different) Email How did you hear about us?
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:
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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,
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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
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Patient Last Name: First MI. Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone:
Patient Last Name: First MI Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security No.: Sex: Marital Status:
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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
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Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
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:
Statement of Financial Responsibility
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Medication History (List all medications that you currently take with the dose)
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Orthopaedic Specialists, P.L.L.C. PATIENT INFORMATION Date: Patient s Last Name First Middle Initial Home Phone No. Street Address City and State Zip Code Cell Phone No. Social Security No. DOB Age Sex
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
Patient Health History Form
Patient Health History Form PATIENT INFORMATION Patients Legal Name: Name that child likes to be called (Nickname): DOB: Current Age: SOURCES OF INFORMATION Name of Person Providing Information: Relationship
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION GENERAL PATIENT INFORMATION (Please Print) Patient Name: of Birth: Sex: Male Female Marital Status: Single Married Divorced Other Street Address: Home Phone: City/State: Zip: Cell
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
WESTBANK PLASTIC SURGERY, L.L.C. JONATHAN C. BORASKI, M.D., D.M.D.
JONATHAN C. BORASKI, M.D., D.M.D. 1111 Medical Center Boulevard Suite South 640 Marrero, Louisiana 70072 Phone (504) 349-6460 Fax (504) 349-6463 Welcome to Westbank Plastic Surgery!! Please present your
Palm Valley Oral and Maxillofacial Surgery
Palm Valley Oral and Maxillofacial Surgery PATIENT INFORMATION: Male Female Single Married Divorced Widow Minor Name Soc.Sec # Address Apt# City State Zip Home Phone # Work Phone # Cell# Date of Birth
PATIENT SIGNATURE: DATE:
NAME: DOB: DATE: PRIMARY CARE PHYSICAN: REFERRING PHYSICAN: REASON FOR VISIT TODAY: E- MAIL: PHARMACY: PHARMACY TELEPHONE #: MEDICATIONS (Include nonprescription drugs, Vitamins, and Herbal drugs) Do you
ADVANCED VEIN & VASCULAR SOLUTIONS Board Certified Vascular Surgeons
ADVANCED VEIN & VASCULAR SOLUTIONS Board Certified Vascular Surgeons We would like to thank you for choosing Advanced Vein & Vascular Solutions for your care. We are committed to providing you with quality
Employed Unemployed Retired Student Full Time Part Time Employer Name: Employer Phone #: Occupation:
Marietta Office Towne Lake Office Patient Registration Form DATE / / Physician (Please check one) Dr. Kelley Dr. Huffman Dr. Windom Dr. Chappell Dr. Tackitt Dr. Killian When calling for today s appointment:
ADDRESS: APT#: CITY: ZIP: IF ANOTHR PHYSICIAN, WHO?
PEDIATRIC PATIENT INFORMATION SHEET ENT & AUDIOLOGY CENTER OF SOUTHLAKE PHONE: (817) 416-9731 FAX: (817) 416-9751 PATIENT NAME (LAST, FIRST, MIDDLE) AGE: SEX: ADDRESS: APT#: CITY: ZIP: PATIENT HOME PHONE:
Female Patient Questionnaire & History
Female Patient Questionnaire & History Name: Today s Date: (Last) (First) (Middle) Date of Birth: Age: Occupation: Home Address: City: State: Zip: E-Mail Address: May we contact you via E-Mail? ( ) YES
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
New Patient Paperwork Current Insurance Card Valid Driver s License It is also important
Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of our Frisco practice that focuses on Pediatric Plastic Surgery. All appointments
Sleeping pills. Thyroid medicine. Headache pills. Medicine for Arthritis. Birth control pills Insulin or diabetic pills.
ARE YOU PRESENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? (Check Box/s Below) Aspirin, Bufferin, Anacin Sleeping pills Shots Blood pressure pills Thyroid medicine Water pills Cortisone Headache pills
1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.
Thomas J. Savage, DPM Jay H. Dworkin, DPM PC 1421 S. Potomac Street, Suite 120 Aurora, CO 80012 303.923.3369 www.metrofoot.org 303.923.3882(fax) Please print and complete all parts. Date PATIENT INFORMATION
ADULT PATIENT INFORMATION SHEET ENT & Audiology Center of Southlake 660 W. Southlake Blvd. Suite 100, Southlake TX (817)
ADULT PATIENT INFORMATION SHEET ENT & Audiology Center of Southlake 660 W. Southlake Blvd. Suite 100, Southlake TX 76092 (817) 416-9731 Date: Patient Name: (Last, First, Middle) DOB: SEX: PATIENT INFORMATION
Registration Form. Patient Name Last First Middle. Patient Address Street/Apt# City State/Zip Code. Sex M F Date of Birth Social Security #
Registration Form Home Phone Work Phone Cell Phone Patient Name Last First Middle Patient Address Street/Apt# City State/Zip Code Sex M F of Birth Social Security # Occupation How did you hear of our practice?
Marco A. Vargas, DPM, FACFAS Alicia E. Johnson, DPM W. Grand Parkway South Suite 530 Sugarland, TX Phone: Fax:
For your convenience, and to simplify the billing process, our practice keeps credit cards securely on file This is done to cover incidental charges, such as copayment, coinsurance, and deductible. Please
PATIENT INFORMATION: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) ADDRESS: Street Address City State Zip Code
PATIENT INFORMATION: Date: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) E-MAIL ADDRESS: ADDRESS: Street Address City State Zip Code BIRTHDATE: / / AGE: SSN: SEX: M F OCCUPATION:
PEDIATRIC REGISTRATION FORM
PEDIATRIC REGISTRATION FORM **Today s Date: PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: *First Name: Middle Initial: *Address: City: State: Zip: *Sex: *Date of Birth: Age:
WELCOME TO OUR PRACTICE! We look forward to seeing you very soon.
WELCOME TO OUR PRACTICE! We are glad to welcome you to Park Avenue Oculoplastic Surgeons (PAOS) and Park Avenue Surgery Center (PASC). Enclosed are some materials which will acquaint you with our facilities,
NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX
PATIENT INFORMATION NAME (LAST, FIRST, MIDDLE) SSN# BIRTH SEX ADDRESS CITY, STATE & ZIP CODE EMAIL: MAILING ADDRESS (IF DIFFERENT FROM ADDRESS) CITY, STATE & ZIP CODE HOME PHONE CELL PHONE OTHER PHONE