Welcome, Cheers~ The Team at Partington Plastic Surgery and Laser Center

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1 Welcome, We are delighted that you have chosen Partington Plastic Surgery and Laser Center to help you look and feel your best. Regardless of the procedure(s) you have chosen it is our goal to provide you with the very best experience. For your convenience please complete the enclosed information and bring it with you to your appointment. Bring your insurance card, driver s license, completed forms, and a form of payment. We suggest that you arrive at least 15 minutes early so that we may review your paperwork and make any necessary copies. We have also enclosed driving directions to our Kirkland, WA clinic. Your consultation is scheduled for one hour. Your consultation will begin with one of our Patient Care Coordinators followed by a complete examination by Dr. Partington or Dr. Windle. To make this appointment with your doctor the most beneficial, we suggest that you create a list of questions that you would like answered. We also suggest that you visit our web site to review photos and meet our team. We have set aside this time for you and if for any reason you need to reschedule your appointment we require a minimum of 48 business hours otherwise a $ fee will be charged to your credit card on file. It is our pleasure and privilege to have you as a patient. Please feel free to give us your feedback at any time throughout your journey and thank you, again, for allowing us to service your surgical and nonsurgical needs. Cheers~ The Team at Partington Plastic Surgery and Laser Center NE POINTS DR, SUITE 110, KIRKLAND, WA TEL: FAX:

2 Welcome to Partington Plastic Surgery. We are delighted you are here. Please take a brief moment and complete the following registration forms. Patient: Last Name First Name Middle Initial Address: Street City State Zip Birth Date: Age: SSN#: [ ] Married [ ] Single [ ] Divorced [ ] Widowed Phone: Home: ( ) Work: ( ) Cell: ( ) *** May we contact you for promotions and special events? [ ] YES [ ] NO Your Employer: Occupation: Spouse s Name: Spouse s Employer: **** IN CASE OF AN EMERGENCY**** ****Who will we be notifying**** Name: Relationship: Phone: Home: ( ) Work: ( ) Cell Phone: ( ) Please tell us how you heard about Partington Plastic Surgery? [ ] Physician [ ] Which Website [ ] Friend /Relative [ ] Other With whom do you give us permission to talk to about your medical information? PATIENT SIGNATURE: DATE:

3 PATIENT PRIVACY AND CONSENT, FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS I, hereby consent to the use or disclosure of my protected health information by the practice of Marshall T Partington, M.D., Brian Windle, M.D., hereinafter referred to as ( practice ), for the purposes of diagnosing or providing treatment to me, obtaining payment for my health care or to conduct health care operations. I understand that diagnosis or treatment of me by the Practice may be conditioned upon my consent as evidenced by my signature on this document. I understand that payment for procedures that are aesthetic or cosmetic in nature are my sole responsibility and will not by billed to any third party. I understand that payment for such procedures will be requested in advance for any treatment. I understand there are no warrantees implied or otherwise to the outcome of any treatments or procedure. I have been offered, read and/or understand the Practice s Notice of Privacy Practices, which has been offered to me by the practice, prior to signing this document. I understand that the patient privacy rights and disclosure varies state by state. I understand that the Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment. This Notice of Privacy Practices also describes my rights and the practice s duties with respect to my protected health information. The Notice of Privacy Practices for Partington Plastic Surgery Center is available at the offices of Partington Plastic Surgery Center. Terms of the Notice of Privacy Practices may change. If changes are made, I may obtain a revised copy by calling the office and requesting a revised copy be sent in the mail or by requesting one at the time of your next appointment. Patient Name: Date of Birth: Signature: Date: Other than Patient: Name: Signature: Relationship to Patient: Date:

4 NOTICE OF PRIVACY PRACTICES This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). OUR COMMITTMENT TO YOUR PRIVACY Our practice is dedicated to maintaining the privacy of your health. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information: USE AND DISCLOSURE OF YOUR HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES The following circumstances may require us to use or disclose your health information: 1. To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court administrative order. 3. If required to do so by a law enforcement official. 4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat. 5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To federal officials for intelligence and national security activities authorized by law. 7. To correctional institutions or law enforcement officials, if you are an inmate or under the custody of a law enforcement official. 8. For Workers Compensation and similar programs. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION 1. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable request. 2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records. You must complete the Medical Records Release form and send or bring to Partington Plastic Surgery and Laser Center, NE Points Dr., Suite 110, Kirkland, WA There is a minimum $23.00 fee for copying or mailing this information. NOTE: We must respond to this request within 30 days. 4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Partington Plastic Surgery and Laser Center, NE Points Dr., Suite 110, Kirkland, WA You must provide us with a reason that supports your request for amendment. 5. You are entitled to receive a copy of the Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact the front desk receptionist. 6. If you feel your privacy rights have been violated, you may file a complaint with our practice or the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the Practice Manager at Partington Plastic Surgery and Laser Center. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 7. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. If you have any questions regarding this notice or our health information privacy policies, please contact the Practice Manager at Partington Plastic Surgery and Laser Center. Effective 2/15

5 HEALTH QUESTIONAIRE Full Name: Date: Birth Date: Age: Height: Weight: Primary Care Doctor: Phone #: Specialists: _ Phone #: Please list any medical illness that you have been or are being treated for: Please list all allergies including food, drug and/or topical (i.e. Latex and adhesive): Please list all medications including over the counter drugs, dietary supplements and herbal additives that you are currently taking: Please list all previous minor and major operations along with their approximate dates. This includes any form of cosmetic procedures:

6 Do you have children? YES NO If YES, how many children do you have? Ages: Anesthesia History: (Please check all that apply) [ ] No past anesthesia history [ ] Post-operative nausea and vomiting [ ] Local anesthetic complications [ ] Complications during or after anesthesia. Please Explain: Do you currently have or have you ever been treated for any of the following: (Please check all that apply) [ ] Chronic Pain [ ] Hepatitis A or B [ ] Weakness [ ] Asthma and/ or [ ] HIV/AIDS [ ] Sleep Apnea Bronchitis [ ] Psychiatric Care [ ] Stroke [ ] Acid Reflux [ ] Eye Problems [ ] Pneumonia [ ] Chest pain or any [ ] Cold Sore [ ] Productive Cough [ ] Heart Disease [ ] Diabetes/High [ ] Emphysema [ ] Heart Attack [ ] Blood Sugar [ ] Tuberculosis [ ] Irregular Heart Beat [ ] Thyroid [ ] Shortness of Breath [ ] Blood Clots [ ] Kidney [ ] UTIs [ ] High Blood Pressure [ ] Seizures [ ] Cancer [ ] High Blood Sugar [ ] Sickle Cell [ ] Numbness [ ] None Social History: Do you smoke cigarettes? YES Packs per day: NO Do you drink alcohol? YES Drinks per day: NO Do you use recreational Drugs? YES Usage per day: NO Name: Birth Date::

7 Medical Concerns YES Family History Of NO Family History Of Anesthesia Problems Malignant Hyperthermia Abnormal Bleeding Abnormal Clotting Autoimmune Disorders Cancer Breast Cancer Pulmonary Embolism Diabetes Endocrine Disease Heart Disease High Blood Pressure Von Willebrand Hemophilia Liver Disease Lung Disease Skin Cancer Skin Disease Substance Abuse Aneurysm Afflicted Family Member Notes / Other Family Members Name: Birth Date: :

8 COSMETIC INTEREST Name: Date: We offer many services. To provide you with the best care please check any/all that are of interest to you either now or in the future. Breast Breast Lift Breast Augmentation (Silicone/Saline) Breast Reduction - Mastopexy Breast & Nipple Reconstruction Post Cancer Reconstruction Fat Transfers to Breast Body LipoSculpture Abdominoplasty - Tummy Tuck - Mommy Makeover Body Lift Body Implants Post Weight Loss Surgery (Bariatric) Brachioplasty - Arm Lift Beltlipectomy - Butt Lift Labiaplasty - Fat Transfer Vaginal Fat Transfer to Hips/Thighs Facial Brow & Forehead Lift Blepharoplasty - Eye Lid Lift Rhinoplasty - Nose Reshaping Facelift Neck Lift The Cameo Lift Silhouette-Lift Fat Transfers to Face Ear Lobe Otoplasty Chin Augmentation Neck Liposuction Vaginal Rejuvenation G-Spot Amplification Labiaplasty Additional Services & Procedures Laser Resurfacing Pro-Fractional Laser Laser Hair Removal Procedures for Men Laser - MicroLaserPeel, Gynecomastia - Male Breast Reduction SkinTyte, BBL Abdominoplasty Male Pectoral Implants Cheek Implants Body Lift Liposuction Injectables (see next column) Blepharoplasty - Eye Lid Lift Facelift Rhinoplasty - Nose Reshaping Otoplasty - Ear Lobe Neck Lift Neck Liposuction Laser Hair Removal Scar Revision Spider Vein Therapy Latisse Chemical Peels Facial Waxing Mole Removal Hand Surgery Injectables Botox Artefill/Bellafill Filler; Juvederm, Restylane, Perlane

9 Insurance Registration Form Primary Health Insurance Company: Primary Cardholder: Birth Date: Employer: Policy #: Group #: Insurance Phone #: Referral Required? No Yes Co-Pay? No Yes How Much $ Secondary Health Insurance Company: Primary Cardholder: Birth Date: Employer: Policy #: Group #: Insurance Phone #: Referral Required? No Yes Co-Pay? No Yes How Much $ I hereby authorize payment of any surgical and/or medical benefits directly to Dr. Marshall T. Partington/Dr. Brian Windle of Partington Plastic Surgery Center for his services. I AGREE TO PAY ALL CHARGES THAT EXCEED OR THAT ARE NOT COVERED BY INSURANCE. I understand that Dr. Marshall T. Partington/Dr. Brian Windle does not bill secondary insurance and that I am responsible to bill my own secondary insurance if applicable. I understand that Dr. Marshall T. Partington/Dr. Brian Windle will bill my health insurance as a onetime courtesy and that rebilling is not customary. I understand that I am responsible to follow up with my insurance company if there are any discrepancies or lack of payment for services rendered. I understand that it is my responsibility to make sure that I have coverage to see Dr. Marshall T. Partington/Dr. Brian Windle. It is also my understanding the Dr. Marshall T. Partington/Dr. Brian Windle run a for profit health care service, and that any service, supplement, or skin care product falls under the for profit umbrella. Authorization to Release Medical Information to Insurance Co. and Other Medical Offices: I hereby authorize Dr. Marshall T Partington/ Dr. Brian Windle of Partington Plastic Surgery Center to release any information acquired during the course of my examination on treatment. NAME: DATE OF BIRTH: PATIENT SIGNATURE: DATE: Authorization for Quality Assurance And Peer Review: I hereby authorize Marshall T. Partington/Brian Windle of Partington Plastic Surgery Center to disclose information to those individuals qualified for the purpose of medical quality assurance and peer review. PATIENT SIGNATURE: DATE:

10 From I-405 going South (from Everett) South towards BELLEVUE/RENTON Merge onto 520 West via EXIT 14 towards SEATTLE (FOLLOW DIRECTIONS BELOW FOR 520-WEST) From I-405 going North (from Renton) North towards BELLEVUE Merge onto 520 West via EXIT 14 towards SEATTLE (FOLLOW DIRECTIONS FOR BELOW 520-WEST) From WA-520 going East (from Seattle or I-5) 520 East towards BELLEVUE/KIRKLAND Take the exit toward LAKE WASHINGTON BLVD. NE Merge onto BELLEVUE WAY NE, get into your left lane Take a LEFT turn onto NE POINTS DR NE POINTS DR is immediately on your RIGHT We are the first building on your left in the PLAZA YARROW BAY office complex. Look for a purple UW sign on the outside of the building. Go straight through the main entrance/front doors past the elevators. We are located at the end of the hall. From WA-520 going West (from Redmond) 520 West towards SEATTLE Take the 108TH AVE NE exit Turn RIGHT off the exit onto 108TH AVE NE Take your next immediate LEFT onto NORTHUP WAY NORTHUP WAY becomes NE POINTS DRIVE NE POINTS DRIVE is the first immediate RIGHT after you go through the Bellevue Way/Lake Washington Blvd intersection. We are the first building on your left in the PLAZA YARROW BAY office complex. Look for a purple UW sign on the outside of the building. Go straight through the main entrance/front doors past the elevators. We are located at the end of the hall NE POINTS DR, SUITE 110, KIRKLAND, WA TEL: FAX: