Dr. Daria Hamrah Patient Information (Facial Cosmetic Procedures and Laser Treatment)
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1 Dr. Daria Hamrah Patient Infrmatin (Facial Csmetic Prcedures and Laser Treatment) PATIENT: New Pt. / Frmer Pt. f Visit First Name M.I. Last Name Sex: M / F f Birth / / Age SS# - - Credit Card*# Exp: Hme Phne ( ) Cell Phne ( ) Street City State Zip Referred By/ hw did yu fund us: Emergency Cntact Persn: Phne ( ) Student: (Full time / Part time / Nt) Schl City Emplyed: (Full time / Part time / Retired / Nt) Married / Divrced / Widwed / Separated / Single Wh will be respnsible fr yur accunt? (Self / Spuse / Father / Mther / Other) Name Hme address (if different) City State Zip REASON FOR VISIT: Face Lift (Rhytidectmy) Neck Lift (Platysma plasty) Dimple-Plasty (Cheek dimples) Btx/Dysprt Facial and Neck Lipsuctin Ear Repair (Trn earlbes) Juvederm Endscpic Brw Lift (Frehead lift) Ear Surgery (Otplasty) Restylan/ Perlane Eyelid Surgery (Blepharplasty) Laser Skin (face Resurfacing) Radiesse Nse Surgery (Rhinplasty) Laser Hair Remval Skincare/ Facial Jaw Recnstructive surgery Chemical Peels Auricular Therapy Lip Augmentatin (including Implant) Dermabrasin Hair Analysis Facial Implants (Chin & Cheek) Micrdermabrasin Other Service: *Credit card number is required in the event f any utstanding balance ver 30 days due t NOVA SurgiCare, PC Updated 6/7/11
2 HEALTH HISTORY NOVA SurgiCare, PC Dr. Daria Hamrah Are yu under a physician s care fr a particular cnditin? If s, fr what? Have yu had any serius illness, peratins, r hspitalizatins? If s, describe Are yu pregnant, nursing a child, r planning a pregnancy? Have yu been tested fr tuberculsis? Results Have yu been tested fr hepatitis? Results D yu take r have yu taken radiatin r chem treatment fr cancer? If s, date D yu take r have yu taken intravenus bisphsphnates (examples: Aredia, Zmeta)? If s, date D yu smke? Numbers f packs per day Hw lng have yu been a smker? Have yu had any type f implant surgery dne? If s, list type and date f surgery D yu have any ther health prblems that the dctr shuld be aware f? Please list DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (Please Circle) Heart Attack / Heart Surgery Strke High Bld Pressure Jaundice Ulcers Mitral Valve Prlapse Epilepsy r Seizure Thyrid Prblems Abnrmal Bleeding Anemia Prir Bld Transfusin Emphysema Asthma / Brnchitis Shrtness f Breath Severe Cughing Heart Murmur Cld Sres Alchl r Drug Dependence Cngenital Heart Disease Pneumnia Rheumatic Fever Glaucma Kidney Disease Bruises Easily Sinus r Nasal Prblems Diabetes Breast Cancer/ Prstate Cancer MEDICATIONS: Are yu allergic t any f the fllwing? (Please check yes r n) YES NO YES NO Lcal Anesthetic Aspirin / Ibuprfen Pencillin / Amxicillin Cdeine Latex / Rubber Prducts Sulfa Drugs Barbiturates / Sedatives Other N Knwn Drug Allergies (Please Circle) Are yu currently taking any f the fllwing? (Please check yes r n) YES NO YES NO Tagamet Thyrid Medicatins Antibitics r Sulfa Drugs Anticagulants High Bld Pressure Meds Sterids Tranquilizers Insulin / Diabenase Heart Medicatins Aspirin / Ibuprfen Qty Antihistamines / Decngestants Weight Lss / Herbal Supplements Fsamax / Bniva / Actnel/ Zmeta Immune Suppressants Please list any thers I certify that I have read and understd the questins abve and that the abve infrmatin is current and crrect. I will nt hld my surgen, Dr. Daria Hamrah, r any f his staff respnsible fr any errrs r missins that I have made in the cmpletin f this frm. In additin, I am authrizing my credit card (number prvided n page 1) t be charged fr any utstanding balance f any 30 days verdue t NOVA SurgiCare, PC. Patient / Legal Guardian Signature Page 2
3 Dr. Daria Hamrah Financial Plicy - Elective Prcedures This ffice will accept the fllwing frms f payment fr services rendered: Cash, Check, American Express, Discver, MasterCard, and Visa. Optinal financing plans are als available (Care Credit). In rder t schedule a prcedure and t secure yur desired date, we must btain 30% f yur ttal surgery amunt as a depsit. The remaining balance f the fees will be due upn yur preperative visit r ne week prir t yur prcedure. The depsit will be applied twards yur elective prcedure, hwever, if the prcedure is canceled less than 7 days prir t yur scheduled surgery date fr any reasn, depsit wuld be nn-refundable except in case f dcumented emergency r medical disability. If revisinary treatments are desired during the first year, there will be n surgen s fee, hwever the cst f surgical supplies, facility fee and anesthesia will be the respnsibility f the patients. Any further treatment will reflect the usual prcedural fees. There is a $50.00 charge fr pst-perative appintments after 90-days frm yur surgical date. These glbal care standards are set frth by the American Medical Assciatin. Any lab wrk required fr yur elective prcedure will be the sle respnsibility f the patient. Overpayments will be prcessed and refunded t the apprpriate party accrding t generally accepted prcedures. Refunds due t the patient/guardian will nt be prcessed and remitted until all active and past due, including bad debt, accunts have been paid. This prcess generally takes abut 60 days. It is ur plicy t charge a $25.00 fee fr all returned checks. Please be aware that under n circumstances des this ffice file insurance fr elective csmetic prcedures. This applies regardless f participatin in patients plan. Patient understands and accepts that this ffice will assist in prviding a receipt f services rendered n day f surgical prcedure. Any reimbursement received by insurance plans will be patient s respnsibility and patient understands that fr such csmetic prcedures, negtiated rates will nt apply. All patients are charged the same fr same services rendered, and this ffice des nt accept reasnable and custmary charge calculatin by utside parties unless prvided in an arrangement such as a managed care cntract. I have read and agree t the abve plicies. I understand that it is my respnsibility t pay any fees t this ffice. This signature n file is als my authrizatin fr the release f infrmatin necessary t prcess any insurance claims and credit card fr any unpaid balance. I hereby authrize payment t this dctr named f the benefits therwise payable t me. Patient/Legal Guardian Signature
4 Patient Disclsure Instructins In general, the HIPAA privacy rule gives individuals the right t request a restrictin n uses and disclsures f their prtected health infrmatin (PHI). The individual is als prvided the right t request cnfidential cmmunicatins r that a cmmunicatin f PHI be made by alternative means, such as sending crrespndence t the individual s ffice instead f the individual s hme. I wish t be cntacted in the fllwing manner (check all that apply): Hme Telephne: O.K. t leave message with detailed infrmatin Leave message with call-back number nly Written Cmmunicatin: O.K. t mail t my hme address O.K. t mail t my wrk/ffice address O.K. t fax t number indicated Other (Fax/Cell, etc.) Wrk Telephne: O.K. t leave message with detailed infrmatin Leave message with call-back number nly I allw yu t give my clinical infrmatin t r answer questins frm (check all that apply): Spuse Parent Child Other: (specify): Nne Patient Signature Print Name Birth date
5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *Yu may refuse t sign this acknwledgement* I have received a cpy f this ffice s Ntice f Privacy Practices. Printed name Signature FOR OFFICE USE ONLY This ffice attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatins barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Specify) Subsequent law changes may require frm revisin
6 NOVA SurgiCare, PC Dr. Daria Hamrah Authrizatin Fr Release and/r Publicatin f Phtgraphs* I hereby authrize the release any/ all f the phtgraphs taken preperatively, during surgery, r pstperatively, withut limitatin regarding my physical and mental cnditin. I cnsent t these phtgraphs fr the purpse f patient viewing (befre and after gallery), teaching r jurnal publicatin fr NOVA SurgiCare, PC and Dr. Daria Hamrah. Name f Patient f Birth Scial Security # Patient r Legal Guardian Signature Witness Signature *NOVA SurgiCare can use patients befre and after pictures fr the purpse f teaching, jurnal publicatins, befre and after picture gallery (internet/ advertising), assuming patients identity is deleted r hidden (ie: nse surgery, nly shwing the nse) withut patients cnsents.
7 Financing Optins NOVA SurgiCare is pleased that yu have chsen ur practice t assist yu with yur dental implants and csmetic gals. We are glad t assist yu with any financing that yu may desire fr yur prcedure(s). We have had successful relatinships with the fllwing cmpanies and will assist yu with any questins yu may have regarding financing. Rates and terms vary by cmpany and n applicant s credit histry. SurgeryLans.cm CsmetiCredit Upn ntifying either f these cmpanies directly they will send yu an applicatin t cmplete and return fr credit verificatin. Upn apprval they will issue funds directly t us. All surgical fees will be due and payable t Dr. Hamrah at yur preperative visit, which is 1-2 weeks prir t yur desired surgical date. When applying fr financing, make sure yur cmpany knws that the lan must be funded 1-2 weeks prir t surgery. This ffice als accepts Cash, Checks, Visa, MasterCard, American Express and Discver fr yur cnvenience. Revised: 08-10
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