West Coast Plastic Surgery Center, Inc.
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- Hugh Morrison
- 5 years ago
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1 West Coast Plastic Surgery Center, Inc. Today s : Yuly Gorodisky, D.O. Plastic and Reconstructive Surgeon Agoura Road, Suite 220 Westlake Village, CA (818) Patient s Name: of Birth: Age: address: Home Address: City State Zip Social Security #: Home Phone#: Cell Phone#: Occupation: Employer: Marital Status: Spouse Name: Spouse Occupation: Spouse Phone #: Family Physician/Internist: Phone # Address: How did you hear about our practice? Emergency Contact: Name: Relationship: Home Phone: Work/Cell Phone: Purpose of Today s Visit: Please specify in your own words: Please circle the procedure(s) you are interested in: Breast Augmentation (implants) Tummy Tuck Thigh/Buttock Lift Lip Augmentation Face Lift Brow Lift Rhinoplasty (nose surgery) Skin Care Products (Obagi, Vivite, Latisse) Reconstructive Surgery Breast Lift/Reduction Liposuction Gynecomastia Surgery Chin Augmentation Neck Lift Eyelid Surgery Ear Surgery Vaginal Rejuvenation Injectable Treatments (Botox, Juvederm) Previous Surgeries/Hospitalizations:
2 Medications: Please list any medications you are taking: (include Vitamins, Herbal supplements, Birth control pills, etc.) Do you have any Allergies to medications, food, etc.? Medical History: Height: Weight: Have you ever been pregnant? If yes how many times? How many children do you have? Are you pregnant now? When was your last menstrual cycle? Have you gained or lost a significant amount of weight in the last year? When was your last mammogram? When was your most recent physical? Where? Did you have an EKG? Chest X-ray? Do you smoke? If yes, how much per day? Does anyone in you household smoke? Do you consume alcohol? If yes, how much per day? Do you drink coffee, tea, other caffeinated beverages? How much per day? Emotional History: Do you have any significant emotional problems? If yes, please explain Have you ever had Psychiatric/Psychological Care? If yes, please explain Have you ever been diagnosed with Body Dysmorphic Disorder? Surgery Related History: Have you ever had a bad reaction while being put to sleep for surgery? Have any of your family members ever had problems with anesthesia? Do you bleed easily from cuts, surgery, tooth extractions? Do you bruise easily, form large scars or keloids? Family Medical History: Do any of your relatives have any of the following (if yes, who): Tuberculosis Cancer Diabetes Epilepsy Heart Disease High Blood Pressure Lung Disease Kidney Disease Blood or Bleeding Disorder Asthma Mental Disorders
3 I certify that the information provided on this form is true and accurate and there are no omissions from my medical history. I am responsible to notify the office and the physician if any changes occur in my medical condition. If I fail to keep the doctor informed of my full medical history, I may be at an increased risk for complications or unexpected results from the planned treatments. Authorization for Photography and Use of Photographs: I authorize Dr. Gorodisky and the West Coast Plastic Surgery Center, Inc. to take photographs, images, video, etc. as may be deemed necessary to document and plan my treatment and outcomes. I authorize the use of these images for the purpose of public education, professional advancement, medical education, for insurance purposes, and for promotion of the practice. My identifying information will not be used in these photographs. I authorize my photographs to be shown to prospective patients and on Dr. Gorodisky s website. I may request to have those photos removed at any time.
4 West Coast Plastic Surgery Center, Inc. Yuly Gorodisky, D.O. Plastic and Reconstructive Surgeon Agoura Rd, Suite 220 Westlake Village, CA (818) Financial Policy Thank you for choosing us as your health care provider. We are committed to your treatment by being diligent in all aspects of your care. Please understand that payment of your bill is necessary for us to continue to provide treatment for you. We request that you read and sign this Financial Policy prior to initiating any treatment. All Patients must complete the Patient Information forms prior to seeing the doctor Full payment or co-payment/deductible is due at the time of service We accept Cash, Checks, and Credit Cards Any bank charges for returned checks will be added to the balance Financing is available through Care Credit This office participates with the following insurance companies: Blue Cross Blue Shield United Health/Pacificare Cigna Aetna HealthNet Medicare If you have another type of insurance and we are not a participating provider, we will help you to submit your claim, and the reimbursement will be provided to you by your insurance company according to your policy. To reserve a surgery date, a non-refundable deposit of $500 is required and will be credited toward your total surgery fee. If the surgery date is to be changed, the deposit will be applied for the new date. Payment in full is due at the time of your preoperative visit, which is usually within 2 weeks of the surgery date. I have read and understand the Financial Policy. By signing below I indicate my agreement with the above statements.
5 West Coast Plastic Surgery Center, Inc. Yuly Gorodisky, D.O. Plastic and Reconstructive Surgeon Agoura Road, Suite 220 Westlake Village, CA (818) Occasionally we may need to contact you regarding your medical care, please check all that apply. I wish to be contacted in the following manner: Home Telephone: Leave a Message with detailed information Leave a Message with a call back number Work Telephone: Leave Message with detailed information Leave Message with a call back number Written Communication Mail to home address Fax to this telephone number: I hereby give my permission for the West Coast Plastic Surgery Center, Inc. and Associates to disclose the information regarding my treatment to: Spouse: Son/Daughter: Parents: Other: Physician: In signing this release, I authorize my medical records to be faxed or mailed to West Coast Plastic Surgery Center, Inc.
6 Insurance Information (if applicable): Primary Insurance Company Claims Address Telephone Number ID # Group Name/# Subscriber(primary insured) Subscirber SS# Birth Subscriber s employer Relationship of Patient to subscriber Secondary Insurance Company Claims Address Telephone Number ID # Group Name/# Subscriber(primary insured) Subscirber SS# Birth Subscriber s employer Relationship of Patient to subscriber Assignment of Insurance/Medicare Benefits I, the undersigned, directly assign to the West Coast Plastic Surgery Center, Inc. and Yuly Gorodisky, D.O., all surgical and/or medical benefits otherwise payable to me by Medicare, Private Insurance, or any other health plan for services rendered to me or my dependents. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize any holder of medical or other information about me to release any information necessary to secure the payment of benefits. I authorize any holder of medical or other information about me to release this information to my insurance company; its intermediaries or carriers, to my attorney or another physician s office. I also permit a copy of this information to be used in place of original. This statement will remain in effect until revoked by me in writing.
St. Petersburg Center for Plastic Surgery JOHN J. O BRIEN, Jr., M.D. Pg. 1
St. Petersburg Center for Plastic Surgery JOHN J. O BRIEN, Jr., M.D. Pg. 1 Social Security # Date Patient s Name (First) (Middle Initial) (Last) Age Date of Birth Married Single Widowed Divorced Separated
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
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY (518) PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province:
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 &
Personal Medical History Form Please Print
Personal Medical History Form Please Print PATIENT S LEGAL NAME: REFERRED BY: REASON FOR VISIT: TODAY S DATE: BIRTH DATE: PLEASE ANSWER ALL OF THE QUESTIONS AS ACCURATELY AS POSSIBLE. IF YOU DO NOT UNDERSTAND
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:
Arizona Center for Aesthetic Plastic Surgery Steven H. Turkeltaub, M.D., P.C. Certified, American Board of Plastic Surgery
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
JEFFREY M. NELSON, M.D. (520)
JEFFREY M. NELSON, M.D. (520) 575-8400 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name Address First Middle Last Street & Apt # City
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:
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:
COSMETIC HISTORY FORM
COSMETIC HISTORY FORM IF THIS IS YOUR FIRST VISIT WITH US, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone:
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 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:
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS General Information Date: Patient Name: Date of Birth: Age: M.I. How would you like to be addressed by our office staff? Sex: Marital Status: Spouse
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 s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
PATIENT INFORMATION: Patient s D.O.B: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: Home Phone: Cell Phone: Work Phone: Email
Please complete entire form
Please complete entire form Patient Name: (Last) (First) (M) Address: City: State: Zip: DOB: Age: Sex: M F Social Security #: (If Using Insurance this is required) Home Phone: Cell Phone: Work Phone: Marital
Andrea Simons, DPM Davina Cross, DPM Schavey Road, Suite 2, DeWitt, MI (517) Patient History. Name: (First) (MI) (Last)
Today s : Andrea Simons, DPM Davina Cross, DPM 13105 Schavey Road, Suite 2, DeWitt, MI 48820 (517) 668-6166 Patient History of Birth: Social Security #: Name: (First) (MI) (Last) Prefers to be called Address:
Patient Information Form
Patient Information Form Patient Name: Today s : Address: City: State: Zip: Home Phone: Cell Phone: Carrier: DOB: Age: Gender: Social Security Number: Employer Name: Occupation : Address: Email Address:
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS General Information Date: Patient Name: Date of Birth: Age: M.I. How would you like to be addressed by our office staff? Sex: Marital Status: Spouse
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ARE YOU CURRENTLY PREGNANT: Yes No
PATIENT REGISTRATION FORM Last Name (Print) (First) (MI) (Previous/Maiden) Social Security# DOB Marital Status: Single Married Divorced Sep. Widow Address City State Zip Home# Work# Ext Cell# Circle best
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
NEW PATIENT REGISTRATION
NEW PATIENT REGISTRATION Today s Date: Patient s Last Name First Name: Mid. Initial: Date of Birth Age: Sex: F M Marital Status: S M D W Patient s Social Security Number Driver s License No. Home/Mailing
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Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
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: Phone: Insured/Responsible Party Patient Information Name: Address;
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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?
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Cosmetic Interest Questionnaire
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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
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PATIENT REGISTRATION FORM. Address. Street# Street Name Apt.# City State Zip Code. Employer: Date of Birth: / / Age Month Day Year
PATIENT REGISTRATION FORM Name: Jr. Sr. First Middle Last Prefer to be called: Gender(Sex): M F Married Divorced Single Widowed Race : White Black Asian Indian Other Declined to Provide Ethnicity: Hispanic
Patient Registration Form
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Sleeping pills. Thyroid medicine. Headache pills. Medicine for Arthritis. Birth control pills Insulin or diabetic pills.
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NEW PATIENT INFORMATION
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New Patient Registration Form
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Patient or Parent/Guardian Signature:
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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
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DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Last Name: Title: First Name: Middle Name: Nick Name: Marital Status: Address: City State Zip Code Home Phone: Work Phone: Cell Phone: SS#: DOB: Sex: Referring Dr: Referring
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
Patient Information Last Name First Name Middle Initial
Patient Information Last Name First Name Middle Initial Street Address Apt# City State Zip Code Social Security # Home Phone Cell Phone Email D.O.B Sex(M/F) Occupation Relation to Insured Self Spouse Child
Past Medical & Surgical History (Please list any diseases or conditions that you have now or have ever had) (DO NOT LEAVE BLANK)
Date of visit: Name: SS#: - - DOB: / / Race: Ethnicity: Language: Reason for your visit today: Referring physician: PCP: Best number to reach you for your test results: May we leave a message? Yes No Male
Dry Creek Family Dentistry
Dry Creek Family Dentistry A. Dianne Bustamante, D.D.S. Robert D. Eto, D.D.S. Patient Information PLEASE PRINT NAME PREFERRED ADDRESS CITY STATE ZIP BIRTHDATE HOME PHONE SS# CELL PHONE CIRCLE ONE: minor
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:
SKYPE CONSULTATION DISCLOSURE & CONSENT
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
Byron J. Van Dyke, M.D. Medical, Surgical, & Cosmetic Dermatology 1158 N. Court Street, Redding, CA Tel (530) Fax (530)
PATIENT: Date of Birth Gender: Male Female Ethnicity: Hispanic Non-Hispanic Single Married Divorced Widowed Race: Caucasian/European-American African/African-American Asian/Asian-American Native American
BenchMark Rehab Partners Welcome to
BenchMark Rehab Partners Welcome to At BenchMark Rehab Partners we believe communication is essential to achieving the best possible patient outcomes. Understanding your needs and expectations is essential
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 REGISTRATION FORM CAROLINA EAR, NOSE & THROAT
PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT Last Name: First: M.I.: Sex: Age: Date of Birth / / Social Security # - - Race: Ethnicity: Language Spoken: If patient is child / under 18: Parent
PATIENT REGISTRATION FORM
Today s PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First: Mi. Init: DOB: Age: SSN: Gen: M F Marital Status: S M D W Race: African American American Indian Asian Caucasian Hispanic Pacific
CITRUS ORTHOPAEDIC AND JOINT INSTITUTE PATIENT INFO. SHEET
CITRUS ORTHOPAEDIC AND JOINT INSTITUTE PATIENT INFO. SHEET DATE: TIME: DR: PATIENT INFO: PRIMARY CARE DOCTOR: REFERRING: NAM E: First Middle Last SEX: AGE: DOB: SS# RACE: ETHNICITY: Hispanic Non Hispanic
KRAIG R. PEPPER, D.O. P.A.
Thank you for choosing Dr. Kraig Pepper, D.O. P.A. for your care. The following is required to provide you with the quality medical care. The doctor and staff will review this information and place it
MESSIEH ORTHOPEDICS Page 1 MICHAEL S. MESSIEH, M.D. DEMOGRAPHICS/INSURANCE INFORMATION. Patient name: Date of Birth: / / SS#: Race:
MESSIEH ORTHOPEDICS Page 1 MICHAEL S. MESSIEH, M.D. DEMOGRAPHICS/INSURANCE INFORMATION Date: Patient name: Date of Birth: / / SS#: Race: Ethnicity: Language: Home address: City: State: Zip code: Email:
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
Medford Foot & Ankle Clinic, P.C.
MICHAEL A. DEKORTE, DPM, FACFAS* RICK E. MCCLURE, DPM, FACFAS* JEFFERY D. ZIMMER, DPM Dear Patient, Thank you for choosing Medford Foot and Ankle Clinic for your podiatric care. Enclosed are the registration
PATIENT INFORMATION. PARENT OR RESPONSIBLE PARTY (if different from patient)
PATIENT INFORMATION Last Name DOB Home Address Home Phone Driver s License # Employer Name Work Address First Name Age Sex Marital Status Cell Phone SSN Email Work Phone Person to contact in case of an