Renuance Cosmetic Surgery Center Brian Eichenberg M.D., Board Certified Plastic Surgeon Please complete these forms in (black or blue ink) so we can provide the best care possible in helping you achieve your goals. Reason for Visit? Last Name: First Name: M.I. Home Address: City: State: Zip: Home Phone: Cell Phone: Email Address: **Would you like to receive our monthly specials via email: yes no Date of Birth: Age: Sex: F M Marital Status: Single Married Divorced Legally Separated Widow(er) Last 4 of Social Security #: (for identification purposes) Employer: Occupation: Emerg Contact Name: Phone: Relation: How did you hear of us: Google? Yelp? Yahoo!? Radio? LA Fitness? Friend? Who should we thank? Magazine? Which one YourVilla / Inland Empire / Temecula Valley s Best Other? If Patient is a minor, or unable to complete documents, please give GUARDIAN or authorized representative information: Last Name: First Name: Home Address: City: State: Zip: Phone Number: Relation: Insurance Disclaimer Dr. Eichenberg s office is currently not billing any insurance companies. However, under special circumstance, we can provide you with all the necessary information to bill your insurance company yourself. Unless you know your insurance company will be billed for your services at Dr. Eichenberg office, it will be up to the patient and/or guardian to provide insurance information. I assign directly to Brian J.Eichenberg, M.D. and all surgical and/or medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctors to release all information necessary to secure the payment of benefits. Signed:
Medical History Patient Name: Date of Birth: Please answer all of the questions as accurately as possible. If you do not understand the question please ask for assistance. Primary Care Physician: Smoking (type & amount per day): Alcohol (type & amount per week): Phone: If former, Date Quit: Weight: Height: Drug allergies: Previous surgeries & dates: List any medications you are taking, including non-prescription drugs, vitamins and herbs: Has any blood relative ever had the following: Breast Cancer...no yes High blood pressure...no yes Depression...no yes Melanoma...no yes Heart disease...no yes Kidney Disease...no yes Stroke...no yes Diabetes...no yes Please circle if you have ever had the following: Heart disease Cancer Stomach ulcer Arthritis Glaucoma Kidney disease Asthma Rheumatic Fever Thyroid disease Anemia AIDS or HIV+ Stroke Diabetes Hepatitis Tuberculosis Type Bleeding tendency Mitral valve prolapse High Blood Pressure Other Illness: Please circle if you have now or have had within the past year: Weight change Swollen feet/ankles Seizures Dry Eyes Skin Rash Joint or Muscle Pain Chronic cough Chronic diarrhea Swollen lymph nodes Chest Pain Jaundice Easy Bruising Easy Bleeding Rapid heartbeat Depression WOMEN ONLY: Number of pregnancies: Currently Breast Feeding? Date of last mammogram: Was it normal? Do you do regular breast self-examinations?...no yes Breast lump or discharge?...no yes I certify that, to the best of my knowledge, the above represents my current medical status (failure to disclose any information releases my physician from any harm that may result from this lack of knowledge.) Signature: Dr. Signature:
Consent for Purposes of Treatment, Payment & Healthcare Operations Brian J. Eichenberg, M.D., APC and Renuance Aesthetic Care, Inc. Although this form is no longer required for HIPPA compliance, you are being asked to sign this form because it IS REQUIRED for the State of California and/or other compliance. Consent I consent to the use or disclosure of my protected health information by Brian J. Eichenberg, MD for the purpose of diagnosing me or providing treatment to me, for obtaining payment for my health care bills, or to conduct the health care operations of Brian J. Eichenberg, MD APC & Renuance Aesthetic Care, Inc. I understand that diagnosis or treatment of me by Brian J. Eichenberg, MD may be dependent upon my consent as evidenced by my signature on this document. RESTRICTION ON THE DISCLOSURE OF MY PROTECTED HEALTH INFORMATION I understand I have the right to request that Brian J Eichenberg, MD restrict the way my protected health information is used or disclosed in order to treat me, to obtain payment, or for the other healthcare operations of this facility. Brian J Eichenberg, MD is not required to agree to the restrictions that I may request. However, if Brian J Eichenberg, MD does agree to a restriction that I request, the restriction is binding on this facility and its staff. REVOKE CONSENT I have the right to revoke this consent, in writing, at any time, except to the extent that Brian J. Eichenberg, M.D. or this facility already has taken action based upon this consent. DEFINITION OF PROTECTED HEALTH INFORMATION My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. DISPUTES Should a dispute arise related to the cost of services and/or care provided by Dr. Brian Eichenberg or Renuance Aesthetic Care, the patient agrees to pursue appropriate avenues of recourse and will not engage in comments against Dr. Brian Eichenberg, Renuance Aesthetic Care and/or his staff on any Internet blog site and will not indemnify the practice for expenses resulting from such actions. In the event of a failed Small Claims action against Dr. Brian Eichenberg and/or Renuance Aesthetic Care, the patient will compensate him for his time and expense in defending against such action. I also understand payment is due in full the same day the service or procedure is performed. RIGHT TO REVIEW THE NOTICE OF PRIVACY PRACTICES I understand I have a right to review Brian J. Eichenberg, M.D.'s Notice of Privacy Practices prior to signing this document. Dr. Eichenberg's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Brian J. Eichenberg, M.D and Renuance Aesthetic Care. Brian J. Eichenberg, M.D. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices to better protect your personal information. I understand that I can obtain a revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to me in the mail or by asking for a revised notice at the time of my next appointment. SIGNATURE of Patient or Personal Representative DATE PRINT Name of Patient or Personal Representative & Relationship
Dr. Brian Eichenberg There are several items which should be discussed prior to embarking into cosmetic surgery without a general health insurance policy in active effect. 1. Unexpected extra medical cost for unusual medical problems or complications could have an unfavorable effect on your credit or put you deeply in debt if they exceeded your ability to pay for them. 2. In common sense analysis, a persons need for general health insurance coverage outweighs their need for cosmetic surgery. Perhaps, you should consider postponing surgery until after obtaining a general health care insurance policy. 3. No surgery can anticipate the cost of unforeseen medical problems such as rare reactions or allergic reactions to medications or anesthetic medications. The emergency treatment of such problems may be expensive and could require hospitalization or special tests not previously discussed to me by Dr. Brian Eichenberg and his associates. Should hospitalization or expensive testing be needed, I agree that Dr. Brian Eichenberg and his associates may order such testing or medical care as necessary. I agree that I shall be financially responsible for these additional costs and shall not seek reimbursement from Dr. Brian J. Eichenberg and his office. Dr. Eichenberg and his associates have my permission to request any medically necessary tests as may be necessary for my good health as required in an unexpected emergency situation. Please note: Dr. Eichenberg is not contracted with any insurance companies except Medicare. It is your responsibility to verify benefits with your insurance company and pay any amount which they do not cover. In signing this form, I indicate that I understand and have read this form. PRINT Patient Name SIGNATURE of Patient or Personal Representative DATE Witness
Renuance Cosmetic Surgery Center Brian J. Eichenberg, M.D., Medical Director PATIENT PHOTOGRAPHIC AUTHORIZATION AND RELEASE I, _, consent to the taking of photographs by Dr. Brian Eichenberg or his designee of me or parts of my body in connection with plastic surgery procedure(s) and/or aesthetic procedure(s) performed by Dr. Eichenberg and/or his nursing staff. I also consent to have my before and after photos posted on Dr. Eichenberg s website and/or before and after books. I further consent to the release of photographs by Dr. Eichenberg for professional medical purposes deemed appropriate including but not limited to showing these images on public or commercial television, electronic digital networks, for purposes of medical education, patient education, lay publication, or during lectures to medical or lay groups. Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the photographs may portray features which shall make my identity recognizable. I understand that I will not be entitled to monetary payment or any other consideration as a result of any use of these images. Patient Signature: Witness: 24687 Monroe Ave, Murrieta CA 92562 (951) 506-1040, (951) 506-4416 www.renuance.net
Renuance Cosmetic Surgery Center Brian J. Eichenberg, M.D., Medical Director Financial and Appointment Cancellation Policy: Payment is expected at time services are rendered. We DO NOT ACCEPT American Express or checks. We accept Cash, Visa, Discover, MasterCard and Care Credit. To apply for Care Credit, please visit our website at www.renuance.net and click Fees & Financing in Patient Resources. If at any time you DO NOT cancel or reschedule your appointment within twenty-four (24) hours prior to the appointment time, there will be a $25.00 charge to your account, for which you will be responsible for prior to your next procedure. I have read and understood the above statements. I agree to comply with the financial policies of the office and understand that I am financially responsible for my account. Patient Name: Signature: 24687 Monroe Ave, Murrieta CA 92562 (951) 506-1040, (951) 506-4416 www.renuance.net
Cosmetic Interest Questionaire: Renuance Cosmetic Surgery Center Name: Are you interested in learning about the following? Botox Cosmetic for Frown lines between the brows and/or fine lines & wrinkles in the forehead and around eyes Juvéderm XC for Lines around the nose and mouth VOLUMA XC (Juvéderm family of fillers) for a long-lasting MID-FACE lift due to Loss of Volume in the cheek area Please Check To better help us assist you in choosing the correct laser treatment and/or skincare, please answer the following to your best ability Skin Type: Do you have any of the following Ethinicity Background? (may circle more than one) Latisse for Thinning Lashes Light Native American SkinMedica and/or Obagi Nuderm for skin care concerns Olive Asian American Skin Resurfacing for Age Spot Removal (elos Sublative) Dark Native Hawaiian or other Pacific Islander Skin Tightening & Contouring for sagging skin (elos Sublime) Black or African American Skin Rejuvenation for Sun Damage and/or Vascular (elos PhotoFacial/SRA) Do you easily? White American Microdermabrasion Tan Hispanic Smoothbeam for active acne and/or acne scarring Sunburn Other: Laser Hair Removal for Facial and/or Body Hair Spider Vein Therapy Breast Augmentation, Breast Lift or Reconstruction Face and/or Neck Lift Prefer not to answer Liposuction, Body Contouring and/or Tummy Tuck How were you referred? Please Specify Please Check Questions about the office Y or N Friend's name: Was the staff courteous on the phone? Are you a past Patient: Did you get an appointment when you wanted? Magazine: YourVilla / Inland Empire / Temecula Valley's Best Were all your questions answered when you called? or other? Were you greeted in a professional manner during today's appointment? Seminar: Did you wait long to see the nurse or doctor? Referred by another Physician? Please name: Was the office in acceptable appearance? Would you recommend us to a friend or relative? Insurance Co / Legal Consult Other (Suggestions): Internet Search Engine? Google / Yahoo / Yelp / other: Radio station? Which one? Other Start-Up Capital Estimate Sheet1