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1 Nextech Pt. ID Jeffrey Adelglass, MD FACS Medical & Surgical Rejuvenation Centers Patient Information Today s Date _ First Name Last Name Address City State Zip Date of Birth Age SSN Driver s Lic. # Sex: Female Male Martial Status: Single Married Separated Divorced Widow Cell Phone Home Phone Work Phone Occupation What is the best way to contact you? Home Work Cell Mail Emergency Contact Phone Relationship Family Physician Phone City / State Do we have permission to obtain additional health information from your family physician? Yes No *Do you have any allergies or sensitivities? Yes No If yes, please list _ *Are you currently taking any medications, including aspirin, ibuprofen, minerals, herbs, birth control pills, nutritional supplements or sexual performance enhancing drugs? Yes No If yes, please list *Are you allergic to any medications? Yes No If yes, please list Are you currently pregnant or breastfeeding? Yes No ETHNICITY: This information is very important in order for your aesthetician to serve you correctly, and insure the best possible results for your skin treatment. (Please check one) Anglo-Saxon (Caucasian) Hispanic Asian African American Indian Middle Eastern Other (please specify):
2 How did you hear about us? Friend/Family Member (name):_ TV News TV Commercial Radio Talkshow Radio Ad Specify: Newspaper/Magazine Informational Article Printed Advertisement Skintastic.com Internet Search Referred by Other Website (specify): Educational Seminar Event Other Specify: Would you like to receive ongoing information about our products and services, special offers and events? Yes Cell # for Info/Offers: ; No Please do not send me offers and information Other than services we have already provided for you, what additional interests or services would you like to learn more about? Please check all that apply: FACE BODY WELLNESS TREATMENT BY NAME Acne Scar Improvement Cellulite Brain Function ArteFill Permanent Filler Age Spot Reduction Laser Body Sculpting Cholesterol Reduction Botox Cosmetic Chemical Peels Skin Tightening Hormonal Balance DermaRoller Cosmetic Surgery Spider/ Varicose Veins Improve Sleep Quality DOT/SmartXide Drooping Eyelids Unwanted body fat Joint Pain Dysport Facial Lines/Wrinkles Manage Blood Sugar Evolence Facial Skin Tightening GENERAL SKINCARE Mood & Energy Fotofacial IPL Injectable Dermal Fillers Laser Hair Reduction Nutritional Plans Fraxel Laser Recontouring Skin Care Advice Sexual Health Juvederm Laser Skin Resurfacing Skin Tags/Mole Removal Stress Reduction Latisse Redness/Broken Veins Skincare Products Weight Loss/Gain Microdermabrasion Sparse Eyelashes Obagi Products Thin Lips Oxygen Facial Radiesse ReFirme Restylane/Perlane These are the areas that concern me the most Rank: Sculptra Cosmetic Skinmaster 1. _ SmartLipo MPX SmoothShapes 2. _ Thermage Vaser LipoSelection 3. _ VolumaLift Zerona
3 IMPORTANT INFORMATION APPOINTMENTS: In an effort to stay on schedule, please arrive a few minutes prior to your appointment. Being on time for your appointment assures you will receive your full service and that our other clients are not inconvenienced. We reserve the right to reschedule your appointment if you are late. Please schedule your next appointment before you leave. CANCELLATIONS: We respectfully request 48 hours notice for appointment rescheduling and cancellations. A minimum $50.00 fee will be charged for appointments not cancelled at least 24 hours prior to your scheduled appointment time. POLICIES: Product Purchases: Products may not be returned for refunds or credit applied to services; all sales are final. Series Pricing: Series must be paid for in full prior to service to obtain series pricing and are non-refundable under any circumstances. Surgery Deposits/Fees: A $ non-refundable deposit is due when reserving a surgery date with Dr. Adelglass. It is important that you be committed to the date that you have chosen and make it a priority. Because changing this date is a hardship on resources and staff, a $ rescheduling/cancellation fee will be retained for each change you make in surgery date, unless the physician deems the charge or cancellation necessary. The balance of your surgical fee is due in full, 2 weeks prior to your surgery date and can be paid with cash, check, credit card, or financial arrangements with Care Credit Fee Plan. If your payment is not received by the 2 week due date listed above, your surgery will be cancelled and your deposit retained. Returned Checks: There is a $25.00 fee on all returned checks. INSURANCE: Our services are cosmetic and are NOT covered by insurance plans. Patient s SIgnature Date Provider: B R T L Lee Follow Up Date Completed by (Name) Initial Inquiry/Info Given Contact in Future Give Date Products Free Consultation Procedure Scheduled Procedure Completed Comments:
4 THIS DOCUMENT MUST BE SIGNED (BACK OF PAGE, AT BOTTOM) Jeffrey Adelglass, MD FACS Medical & Surgical Rejuvenation Centers NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Dr. Jeffrey Adelglass & Associates has adopted the following privacy policies: Uses and Disclosures Treatment - Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Payment - Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. Health care operations - Your health information may be used as necessary to support the day-to-day activities and management of Dr. Jeffrey Adelglass & Associates. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Law enforcement - Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting. Public health reporting - Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state s public health department. Disputes - Your health information may be disclosed to the appropriate institutions involved in any financial, medical, or legal dispute. For example, should you initiate a financial dispute for any reason, we reserve the right to release your medical information to the involved financial institution(s). Other uses and disclosures require your authorization - Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision. Dr. Jeffrey Adelglass & Associate s Duties We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.
5 PRIVACY PRACTICES CONT Authorization for Phone Calls I authorize the staff of Dr. Jeffrey Adelglass to call my home or work phone number regarding office appointments and/or surgery information. I authorize the staff of Dr. Jeffrey Adelglass to leave a message on my voice mail or telephone recorder regarding office appointments and/or surgery information. Complaints/Contact Person If you would like to submit a comment or complaint about our privacy practices, or if you believe that your privacy rights have been violated; you should call the matter to our attention by sending a letter outlining your concerns to: Julie Latta, Office Manager Dr. Jeffrey Adelglass & Associates 6020 West Parker Road, Suite 400 Plano, TX You will not be penalized or otherwise retaliated against for filing a complaint. Expiration Date of Authorization This authorization is valid for five (5) years from date of signature unless revoked or terminated by the patient or patient s personal representative. Right to Terminate or Revoke Authorization You may revoke or terminate this authorization by submitting a written revocation to Dr. Jeffrey Adelglass and Associates. You should contact the Office Manager to terminate this authorization. Acknowledgment Form I acknowledge receipt of and have reviewed the Notice of Privacy Practices for Dr. Jeffrey Adelglass & Associates, and have been given a copy at my request. Signature of Patient Signature of Patient s Representative Name of Patient (Print or Type) Relationship of Representative to Patient Date Date
6 Jeffrey Adelglass, MD FACS Medical & Surgical Rejuvenation Centers Consent For Medical Photography (Initial Where Applicable) REQUIRED I consent to the use of photographs for recordkeeping purposes; these photographs may be taken before, during, and after my treatment(s), at the physician s discretion. I further consent to the use of these photographs for educational purposes, including presentation at professional medical meetings and lectures, and publication in professional medical journals. I further consent to the use of these photographs for providing information to other clients and to the public about my treatment. They may be shown during client consultations, as well as public promotional lectures and demonstrations, and may be reproduced in educational, instructional, and promotional literature. Restriction for public use: Do not show my entire face (artist will crop photo or mask eyes, to reduce possibility of identification) I also give permission for my photographs to be used on any SKINTASTIC web sites (the above restriction for public use will apply, if box is checked). I am willing to have my SKINTASTIC experience video- and audio-taped for the purpose of educational, instructional and promotional purposes. I am interested in providing additional personal testimonials for future educational, instructional and promotional purposes, for use in print, web, television and radio. Name Date Signature
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