DR. DAVID M. LAVINE CENTER FOR COSMETIC & RECONSTRUCTIVE SURGERY

Transcription

1 PATIENT INFORMATION / INTAKE FORM PATIENT INFORMATION AS OF (TODAY S DATE) Patient Name: Sex: F M (Last) (First) (MI) Address: [Apt or Ste] City: State: Zip: Date of Birth: / / Age: SS #: - - Marital Status: Single Married to Other Cell (Ph):( ) Work (Ph):( ) Home (Ph):( ) Employer and Occupation: Primary Care Physician: PCP phone: Referred by: Doctor/Hospital: Friend/Relative: Website/Online: Other: COMMUNICATION PREFERENCES The Center for Cosmetic and Reconstructive Surgery does not share or sell your contact information. I give permission to receive communication from the Center for Cosmetic and Reconstructive Surgery in the following forms (Check all that apply): Cell Phone Home Phone Work Phone Any restrictions when contacting you? No Yes, please describe IN CASE OF EMERGENCY CONTACT or RESPONSIBLE PARTY (If different from patient) Name: Relationship to patient: (Last) (First) (Middle Initial) Address: (Street) (City) (State) (Zip) Cell Phone: _( ) Work Phone: ( ) PRIMARY INSURANCE (INSURANCE PATIENTS ONLY) Primary Ins Company: Subscriber s Name: DOB: Employer: Policy #: Group Name and/or Number: Page 1 of 5

2 Date Height Weight Age Medical History: Do you have or have you had any of the following conditions? (check all that apply) Heart disease or chest pain Sleep apnea Back / arm / leg pain Asthma Diabetes Fever blisters or cold sores Heart failure Thyroid disease Bleeding Problems Cancer Kidney or bladder disease HIV/AIDS Stroke Stomach trouble or ulcers Psychiatric Diagnosis Seizures High Blood Pressure Hepatitis or liver disease Numbness or weakness Other Please list ALL allergies and reactions Prior surgeries/hospitalizations: Date Complications Medications and/or dietary supplements Social History: (check all that apply) HEALTH INFORMATION / MEDICAL QUESTIONAIRE Do you smoke / dip / chew tobacco? No Yes If so, how often?. Do you drink alcohol? No Yes, if so how many drinks per week: >10 Do you use recreational drugs? No Yes History of substance dependence? No Yes Do you take large amount of aspirin, ibuprofen or vitamin E? No Yes If yes, why? Female Patients: Could you be pregnant? No Yes Do you accept the fact that medicine is not an exact science and every medical/surgical treatment is associated with risk? No Yes TH A VENUE, S UITE 206 F ORT W ORTH, T EXAS ( P ) ( F ) WWW. DRLAVINE. COM

3 REASON FOR VISIT Have you had plastic, cosmetic, reconstructive or hair transplant surgery before: Yes No If yes, please describe Doctor: Date of surgery: Were you satisfied? Yes No If no, please describe: What brings you in today? (check all that apply) Procedures/Treatment Areas of Concern Injections Abdominoplasty/Tummy Tuck Fine Lines and Wrinkles Botox Arm Lift/Brachioplasty Major Lines Around Nose & Mouth Filler Blepharoplasty (Upper Lids/Lower Lids) Skin Texture/Tone Sculptra Breast Augmentation/ Breast Lift Dark Circles/Puffiness Under Eyes Breast Reduction/ Breast Revision Back/Buttocks Browlift Scars Earlobe Repair/Ear Surgery Freckles/Brown Spots Facelift Thinning Lips Facial Liposuction (Neck, Jowls) Cellulite/Stretch Marks Liposuction Face/Neck Lip Enhancement Arms Rhinoplasty Stomach Skin Resurfacing Legs/Thighs Thigh Lift Breasts (specify concern) Other: Other: I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Patient Signature Date Page 3 of 5

4 HIPAA NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT (Individual copies of our Notice of Privacy Practices will be made immediately available upon request) Your signature below acknowledges that you were made available the Notice of Privacy Practices that provide a description of information uses and disclosure practices. You accept and understand that you: Have the right to review the NOTICE prior to signing this consent. Accept that the practice reserves the right to change the NOTICE and its information practices. Have the right to request restrictions on the use or disclosure of your health information to carry out treatment, payment or healthcare operations and to correct error(s) in your record. The practice, however, is not required to agree to the restrictions requested and some services may be unavailable to you depending upon the requested restrictions. May revoke this consent in writing that YOU provide to the practice. The revocation does not apply to any uses of your information made by the practice in reliance upon this consent form and on the belief that your consent was still effective. Initials of patient or person authorized to sign HIPAA Notice for patient (initials) I authorize for detailed messages to be left on an at home answering machine or voic service. (initials) I authorize for detailed message to be left on a cell phone voic . (initials) I agree and offer no objection to the verbal release of protected health information to the person(s) listed below. I also authorize them to pick up prescriptions, notes and other medical information on my behalf. (initials) PATIENT CONSENT FOR CONSULTATION I give my permission for examination and photographs during consultation for the purpose of making an evaluation with regard to my care and treatment. (initials) PATIENT CONSENT FOR USE OF HEALTH INFORMATION PATIENT ACKNOWLEDGMENT AND CONSENT I give my permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery, Inc. I understand that the Board requires that all identifiable characteristics, with the exception of a full face photograph or photograph of a uniquely identifiable characteristic, be blacked out for submission of materials for the Oral Examination of The American Board of Plastic Surgery to protect patient privacy. (initials) TH A VENUE, S UITE 206 F ORT W ORTH, T EXAS ( P ) ( F ) WWW. DRLAVINE. COM

5 AUTHORIZATION FORM FOR RELEASE OF PROTECTED HEALTH INFORMATION I,, hereby authorize David M. Lavine, M.D., The Center for Cosmetic & Reconstructive Surgery and The Medical Skin Care Center, ( practice ) to use and disclose my protected health information for the purposes described in the Notice of Privacy Practices, which I have had an opportunity to read and agree to. This use or disclosure will be made by the office staff of this practice. The health information to be used and/or disclosed is specifically described in the Notice of Privacy Practices, which I have had an opportunity to read and agree to. The person or class of persons to whom the information will be disclosed or who will use the information is described in the Notice of Privacy Practices, which I have had an opportunity to read and agree to. The practice is hereby authorized to make the disclosure to these classes of persons and the aforementioned classes of persons are hereby authorized to use or disclose the information. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the following person at the following address: David M. Lavine, M.D th Avenue, Suite 206 Fort Worth, Texas I understand that a revocation is not effective to the extent that the practice has relied on this authorization and its actions. Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance coverage, as other law provides the insurer with the right to contest a claim under the policy or the policy itself. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations. The practice will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I provide authorization for the requested use or disclosure. I have read all parts of the patient information and authorization form supplied to me by David M. Lavine, M.D. Patient / Guardian Signature Date Patient Name (Please Print) Page 5 of 5