LERGIES (please list name of medication and what happened when you took it. I d codeine)

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Transcription:

NAME DATE OF BIRTH ADDRESS

LERGIES (please list name of medication and what happened when you took it. I d codeine)

Please complete all of the following questions Have you or any family members ever had trouble with: Myself Relative Relationship to you EYES: Visual Loss (one or both eyes) Dry eyes Itching or irritation of the eyes Blurred or double vision Crossed or lazy eyes Cornea problems Thyroid eye disease Wear glasses or contacts Previous eye or eyelids surgery If so please describe what type: NOSE: Difficulty breathing through nose Previous injury to nose Nasal Allergies Frequent nose bleeds Sinus problems Nasal Polyps Previous nasal or sinus surgery If so, please describe what type: FACE/HEAD: Irritation to the face or neck History of radiation for acne treatment Acne Vitiligo Keloid formation Previous face or neck surgery If so, please describe what type: CARDIOVASCULAR: Angina, or history of chest pain Heart murmur Mitral Valve Prolapse History of Heart Attack Congenital heart disease Palpitations or irregular heart beat Stroke High Blood Pressure CHEST: Shortness of breath Shortness of breath when exerting yourself Asthma Chronic lung disease Coughing up blood PSYCHIATRIC: Has there been any recent crisis in your life Do you have claustrophobia Have you ever been treated for drug or alcohol dependency Have you received psychiatric treatment If so, were you hospitalized:

OTHER: Ulcers or stomach problems Gallbladder trouble Seizures or convulsions Kidney problems or urinary tract infections History of tuberculosis Liver disorder: hepatitis or cirrhosis Spinal or back disorders Previous blood clots or thrombophlebitis Free bleeding or bleeding disorders History of blood transfusions Diabetes Autoimmune disease (Lupus, rheumatoid arthritis, etc.) If applicable, are you pregnant Please explain any YES answers here: Do you smoke? How much? Do you drink more than 6 cups of coffee per day? Do you usually drink two or more alcoholic drinks a day Have you been hospitalized for a medical illness? If so, for what reason: Have you ever had a positive blood test for HIV? Please list any questions you would like addressed by Dr. Clymer or the staff: Who can we thank for referring you? Address (if known) Signature

Insurance Information As a courtesy to our patients, we will file your charges for insurance eligible services with your insurance company; however, the following information must be filled out completely for your procedures to be filed with your insurance carrier. By signing below I am authorizing Clymer Facial Plastic Surgery P.C., Dr. Mark A. Clymer to furnish all the necessary information to my insurance company, which they may request to process claims, or to comply with any audits that may be requested by my insurance company. I also authorize transmission of my medical records by fax if the necessity should arise. Insurance deductibles, which have not been met, may require payment prior to your surgery. If this form is incomplete, you will be billed directly. Primary Insurance, Information Primary Insurance Address to mail claims Telephone ID# Group # Policy Holder s Name Policy Holder s SSN# Relationship to member Policy Holder s DOB Policy Holder s Employment Self/Spouse/Child/Other Secondary Insurance Information Secondary Insurance Address to mail claims Telephone ID# Group # Policy Holder s Name Policy Holder s DOB Policy Holder s SSN# Relationship to member Self/Spouse/Child/Other Primary Care/Referring Physician Information Primary Care Physician Referring Physician Phone# Phone# Patients Marital Status married separated divorced single (This information is required by your insurance company. Used for insurance billing only). Responsible Party s Signature Guardian If Patient is under 18 Date Date By signing this form, I understand that if my insurance company does not pay the bill submitted by our office in full, I am responsible for any unpaid balance.

Clymer Facial Plastic Surgery Permission To release/submit Medical Information Date: I hereby authorize Clymer Facial Plastic Surgery and/or Mark A. Clymer M.D.; to submit or send any records or reports, information or correspondence regarding my care or diagnosis, or to request the release of any information required in conjunction with my care or diagnosis, in order to pre-certify or pre-determine a proposed procedure on my behalf. Patient Witness

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