PATIENT SIGNATURE: DATE:
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1 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 take ASPIRIN? YES or NO HEIGHT ft. Inches Marital Status: S M D W WEIGHT lbs. ALLERGIES DO YOU SMOKE? Y N IF YES, HOW MUCH? Packs Have you ever smoked: Y N Alcohol use? Y N IF YES, HOW MUCH? General Medical History (Circle any that apply) Alcoholism Allergies/Hay fever Anemia Anxiety Asthma Atrial Fibrillation Blood Transfusions CAD Cancer Cardiac Pacer Cardiovascular Disease CHF Cirrhosis Colitis COPD CRF Crohn s Disease CVA Depression DM Type 1 DM Type 2 Epilepsy Fracture Gastric Ulcer Gastrointestinal Disease Glaucoma Heart Murmur Hepatitis High Cholesterol Hyperlipidemia Hypertension Hyperthyroidism Hypothyroidism Joint Pain Kidney Infections Kidney Stone Migraine Multiple Sclerosis Obesity Old MI Osteoarthritis Osteoporosis Pneumonia Progressive Neuro. Diso Pulmonary Disease Rheumatic Fever Rheumatoid Arthritis STD Terminal Illness Thyroid Disease TIA Tuberculosis OTHER MEDICAL HISTORY: Surgical Procedures (Circle any that apply) No prior surgical history Appendectomy Breast Lumpectomy Cataract Surgery Colectomy Cone Biopsy D&C Endometrial Ablation Gallbladder Heart Surgery Hemorrhoids Hernia Hysterectomy Laparoscopy Mastectomy Myomectomy Oophorectomy Tonsil/Adenoidectomy Tubal Ligation OTHER SUGERICAL PROCEDURES: Preventative Care Chest X- Ray date Eye Exam date EKG date Labs Drawn date Mammogram date Radiology Group PATIENT SIGNATURE: DATE:
2 CONSENT FOR PHOTOGRAPHS, DIGITAL IMAGING, AND Video In connection with, and in consideration of medical services for which I have been receiving, or am about to receive from Beth A. Collins, M.D.; I hereby consent that clinical photographs, digital imaging, or video may be taken of me, or parts of my body, under the following conditions: The photographs/digital imaging/video shall be taken only with the consent of my physician and under such conditions and at such times as may be approved by him/her. The photographs/digital imaging/video shall be taken by my physician or by a photographer approved by my physician. The photographs/digital imaging/video shall be used for medical record purposes and shall remain the property of Beth A. Collins, M.D. The photographs/digital imaging/video shall be used for website, advertising, meetings, or educational purposes. The photographs/digital imaging/video shall be used for advertising in print and television. Series of Pictures Pertaining To: Signature of Patient/Personal Representative Date Witnessed By Date 2614 Boston Post Road, Guilford Gatehouse West, Suite 16C, Guilford, CT (203)
3 PATIENT NAME: (Last) ( First) (Initial) SS#: ADDRESS: CITY: STATE: ZIP: AGE: DATE OF BIRTH: SEX: M/F MARITAL STATUS S/M/D/W HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) MAY WE CONTACT YOU ABOUT UPCOMING OR MISSED APPOINTMENTS? YES NO PLEASE GIVE PREFERRED CONTACT INFORMATION: EMERGENCY CONTACT: RELATIONSHIP: HOME PHONE ( ) WORK PHONE ( ) HEALTH INSURANCE INFORMATION: Cosmetic patients may give name of insurance company only. Please have your insurance card available for us to photocopy and fill in the information below if you expect insurance to cover non-cosmetic surgery. PRIMARY INSURANCE: INS. CO. PHONE: ( ) MAILING ADDRESS FOR CLAIMS: POLICY OR- ID #: POLICY HOLDERS NAME: POLICY HOLDERS DOB: GROUP NUMBER: SECONDARY INSURANCE: PRIMARY INSURANCE: INS. CO. PHONE: ( ) MAILING ADDRESS FOR CLAIMS: POLICY OR- ID #: POLICY HOLDERS NAME: POLICY HOLDERS DOB: GROUP NUMBER: I hereby authorize Beth A. Collins, M.D. to submit a claim to my insurance carrier or to Medicare for all the covered services, which have been rendered and direct my insurance carrier to issue payment to Beth A. Collin, M.D., P.C. I further authorize the release of any medical information needed by the above to intermediaries to pay an insurance claim. My signature is good for a lifetime of treatment. Beth A. Collins, M.D., P.C. will not bill your health insurance for cosmetic surgery. I understand and agree that I am responsible for any amount not covered by my insurance carrier. SIGNATURE: DATE:
4 Notice of Privacy Practices Acknowledgement And Patient Consent I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow- up among the multiple healthcare providers who may be involved in the treatment directly or indirectly. Obtain payment from third- party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name: Signature: Relationship to Patient: Date: 2614 Boston Post Road, Guilford Gatehouse West, Suite 16C, Guilford, CT (203)
5 PERSONAL INTEREST QUESTIONNAIRE Dear Patient: Our goal is to respond to all of our patient s needs and to provide the highest quality care. In order to provide the information and services you desire on the health and appearance of your skin, we invite you to complete the following questionnaire: Please check all that are of concern to you: Lines around my eyes Crease nose to corner of mouth Lines between my eyes (angry look) Frown on corner of mouth Lines on forehead Brown spots on face Lines under eyes Red, blotchy skin Puffy eyes Excess skin above eyes Thin lips Thin face, no cheeks Dry skin Dimpled chin Oily skin Gummy smile Looking tired Sunk in eyes Please check all that are of interest to you: BOTOX Cosmetic (Botulinum Toxin Type A) BOTOX (Botulinum Toxin Type A) for Hyperhidrosis (excessive sweating) AHA and glycolic peels Skin care advice Juvederm Ultra & Ultra Plus Dermal Filler therapy Skin care products Skin rejuvenation Birthmarks Liver spots/age spots Micro-dermabrasion Sunscreen advice Acne Removing leg veins Chemical peels Facials and eye treatments Laser resurfacing Hair removal Laser treatments Spider vein treatments Longer Lashes Other-please specify: Removing facial veins How did you hear about us? My physician (full name) Ad (specify advertisement) A friend or family member (name) Other
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9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 info@benjamineye.com www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
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:
PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Name Date Street Address City State & Zip Home Phone ( ) Sex Age Date of Birth Cell Phone ( ) Email Address Race Primary Language Employer Occupation Work Phone ( ) May we
Any pertinent medical records
Hello, and welcome to Arizona Pulmonary Specialists, Ltd. You are scheduled to see on at. Please plan to arrive 20 minutes prior to this time. If you are unable to keep this appointment for any reason,
PLEASE. To make your check-in process as smooth and fast as possible: DO NOT DATE THE FORMS BEFORE ARRIVING TO THE OFFICE
PLEASE To make your check-in process as smooth and fast as possible: WRITE LEGIBLY (PRINT) FILL ALL FORMS COMPLETELY DO NOT DATE THE FORMS BEFORE ARRIVING TO THE OFFICE BECAUSE WE WILL SCAN THESE FORMS
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 #
NEW PATIENT INFORMATION FORM Michael Metzger MD Charles Harring MD Andres Ruiz MD Gustavo Cardenas MD Heidi Templin ARNP
NEW PATIENT INFORMATION FORM Michael Metzger MD Charles Harring MD Andres Ruiz MD Gustavo Cardenas MD Heidi Templin ARNP Patient name: Today's Date: / / First Last Referred by: Primary care physician:
LUPTON DERMATOLOGY MR# Today s Date:
LUPTON DERMATOLOGY MR# Today s Date: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name: First Middle Last Address: Street & Apt # City State Zip SS#: Birthdate Age: Sex: Female Male Marital Status:
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:
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
Patient Name: Todays Date: Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status
Patient Name: Todays Date: *General Patient Information Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status Email Phone: Home ( ) - Cell ( ) - Mailing- Address, City, State & Zip *PARENT
GREENWOOD DERMATOLOGY
GREENWOOD DERMATOLOGY Larry J. Buckel, M.D. Thomas J. Eads, M.D. Laura T. Stitle, M.D. Thank you for choosing Greenwood Dermatology for your Dermatologic needs. Dermatologists are the experts in the diagnosis
PATIENT INFORMATION. (Please complete all sections) NAME OF PARENT(S) OR GUARDIAN(S): PARENT, SPOUSE, OR RESPONSIBLE PARTY If Different from Patient
Date: PATIENT INFORMATION (Please complete all sections) Office Location: PATIENT NAME (Last, First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
1. Please bring a Hard Copy of your Current Active Insurance Card, Referral and Photo ID with you.
Welcome to Abeles Dermatology Aesthetic & Laser Arts. We are pleased to be able to help you with all of your Medical and Cosmetic Dermatology needs. Please take a few moments to read this page. Please
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
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;
NOTICE OF PATIENT FINANCIAL RESPONSIBILITY
Lakeview Eye Care Eye Medicine and Surgery Christine C. Platt, M.D. Chad Lehtonen, O.D. One Lakeview Park Rochester, New York 14613 NOTICE OF PATIENT FINANCIAL RESPONSIBILITY At Lakeview Eyecare, we are