PATIENT INFORMATION. Patient s Name Last First Middle Married Single Divorced Widowed. Address Street City State Zip

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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 ( ) Occupation: Cell Phone ( ) Email Address: How were you referred to our office? _ Who to notify in case of emergency? Day Phone: INSURANCE INFORMATION Primary Insurance Carrier _Primary ID #: Name of Insured DOB: Insured S.S.#: Secondary Insurance Carrier Secondary ID#: Name of insured DOB: Insured S.S.#: AUTHORIZATION OF MEDICAL BENEFITS I hereby authorize the Insurance company to pay by check and mail to: Edward M. Kramer, M.D. Inc., 27995 Greenfield Dr., #C Laguna Niguel, CA 92677 The medical and surgical expense benefits allowable and otherwise payable to me under my current insurance policy, as payment toward the total charges for professional services rendered. This payment will not exceed my indebtedness to the above mentioned assigned and I have agreed to pay any balance of said professional service charges, if any, over and above this insurance payment. I further authorize the release of any medical information necessary to process this claim. Signed Date May we leave personal medical information on your answering machine at home? Yes No Do you give our office permission to discuss your medical information with family members? Yes No If yes, please provide their name and relationship. Name Relationship Name_ Relationship I have received a copy of this office s Notice of Privacy Practices (NPP) I have reviewed a copy of this office s Notice of Privacy Practices (NPP) Pt s Initials Pt s Initials

EdwardM.Kramer,M.D,27995GreenfieldDrive#CLagunaNiguel,CA92677 Patient'Name: DOB: Account'#: Gender: History:) Allergiestomedications: Majorproblems:Heart Highbloodpressure Asthmaorotherrespiratoryproblems Othermajorproblemsorillnesses: Isthereafamilyhistoryofskincancer? ormelanoma? Orothermajorillnesses? Haveyoueverhadskincancer? Listallcurrentmedicationsandtopicalcreamsyouareusing: Haveyoueverfaintedorbeenlightheadedwhenhavinganinjectionorsurgicalprocedure? _ Doyoutakeantibioticspriortodentalproceduresorsurgery?

Cosmetic Information Request Form Please let us know if you would like additional information regarding any of the following cosmetic services and procedures: Skin care products for acne control Skin Care Products for adult complexions Latisse for hypotrichosis (inadequate or not enough eyelashes) Microdermabrasion (Power Peel) Skin Rejuvenation Products for Sun Damage and Wrinkles Blotchy skin (uneven pigmentation, freckles, sun damage) Botox treatments for facial frown lines, forehead lines, eyelid lines and lip lines Botox treatments for hyperhidrosis (excessive sweating) Restylane, Juviderm, and Radiesse treatment for lines and wrinkles Sculptra and Voluma treatments for loss of volume in the face Chemical peels for facial skin improvement Laser hair removal Laser skin resurfacing for wrinkles, scars, and acne scars Laser treatment of red spots, brown spots, or blood vessels ThermiVa treatment for vaginal rejuvenation, incontinence, dryness, and decreased sensitivity ThermiSmooth treatment for fine lines around the eyes and mouth ThermiTight treatment for tightening of the neck and other areas Liposuction and Coolsculpting for removal of unwanted fat deposits Mole, wart, cyst removal Eyelid surgery (Eye-tuck) Skin cancer treatment/ Mohs Surgery Earlobe Repair Permanent makeup including eyeliner, eyebrows, or lips Medical grade facials for acne and facial rejuvenation Hydra Facial MD for facial rejuvenation Please let us know how best to contact you: Phone: ( ) -_ Email address: Thank you A staff member will contact you soon to offer further assistance.

DearPatient: The billing department at Aesthetic Dermatology & Laser Center Medical Group Inc., will bill claims for services rendered as a courtesy. The following are the established guidelines that will be followed in resolving your claim. 1. Private*Pay/ WedonotparticipateinanyHMOGtypeinsuranceplans.Ifyouareunsureofyour Cash:* Pt sinitials typeofinsurance,youareresponsibleforpaymentinfullatthetimeofservice. 2. Commercial/ Any cogpayments, deductible, nongcovered services or amounts in excess of PPO/EPO/ POS*Ins: Pt sinitials lifetimemaximumaredueandpayableattimeofservicewiththeentirebalance dueandpayablewithinthirty(30)daysfrominitialbillingdate. 3. Medicare: AnydeductibleornonGcoveredservicesaredueandpayableattimeofservice Pt sinitials withtheentirebalancedueandpayablewithinthirty(30)daysfrominitialbillings. Patients* not* confirming* prior* authorization* and/or* requesting* services* when* authorization* has* been* denied* or* has* not* been* obtained* will* be* billed* as* private* pay* account* and* must* adhere* to* the* guidelines*stated*above*in*the*private*pay*section.* * Accounts* not* resolved* within* fortygfive* (45)* days* may* be* referred* to* an* outside* agency* for* further follow*up,*reported*to*the*local*creditgreporting*bureau,*and*may*result*in*legal*proceedings.**please call*customer*service*at*(714)*229g8246*to*make*payment*arrangements.* * An*administrative*fee*of*$25.00*will*be*charged*for*appointments* cancelled*without*a*24*hour*notice.* MysignaturebelowacknowledgesthatIunderstandmyfinancialresponsibility. Patient/Guarantor Witness Date Date

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