SYNERGY PLASTIC SURGERY

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Patient s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Race Ethnicity Language Any restrictions for contacting you? No Yes E-mail Age Birthdate SS# Gender Female Male Marital Status Single Married to: Other: Patient s Employer Occupation Work Phone Ext: Is it okay to call you at work? Yes No Address Street & Suite # City State Zip How did you hear about Synergy Plastic Surgery? (Mark all that apply) Google Website Phone Book Magazine Newsletter Seminar Realself: Friend/Relative: Doctor: Other: If you were referred by a specific person, may we thank them? Yes No Emergency Contact Relationship to Patient Home Phone Work Phone Other Phone Areas of Interest: (mark all that apply) Facial Procedures Breast Reconstruction Spa Services & Other Procedures Blepharoplasty (Eyelid Lift) Breast Reduction Botox Brow or Forehead Lift Mastopexy (Breast Lift) Laser Hair Removal Earlobe Repair Male Breast Reduction Leg Veins Facial Liposuction (Neck, Jowls) Body Procedures Lesion / Moles Face or Neck Lift Abdominoplasty (Tummy Tuck) Skin Resurfacing (Laser, Peel, etc.) Lip Enhancement Brachioplasty (Arm Lift) Botox/Wrinkle Fillers (injections) Otoplasty (Ear Pinning) Full Body Lift Lip Enchancement Rhinoplasty (Nose Reshaping) Breast Procedures Breast Augmentation Liposuction (Thighs, Abdomen, Etc.) Thigh or Buttock Lift Brazillian Butt Lift (BBL) Labiaplasty I understand that office visit charges are payable on the day service is rendered and that reservation fees may take up to 48 hours to be refunded when applicable. Signature Date

Patient Name: DOB: Age: Marital Status : Weight lbs What surgery are you considering? Height ft in General Information: YES NO Comments: 1. HEART Do you have high pressure Heart Attack Chest Pain Irregular Heart Beat High Cholesterol Family history of heart disease 2. LUNGS A recent respiratory illness Sleep apnea Asthma Wear oxygen during day/night? Family history of lung problems 3. KIDNEY Urinary tract infections Kidney Stones 4. DIGESTIVE TRACT Ulcers Reflux/Heartburn Hepatitis Pancreatitis 5. MUSCLE/BONE Arthritis Muscle weakness 6. NEUROLOGICAL/PSYCH Head injury/stroke Seizures Depression Headaches 7. BLEEDING Bleeding/Clotting problems Family history of bleeding problems? 8. METABOLIC Diabetes Thyroid Problems 9. BREAST Personal history of breast masses/problems? Family history of breast cancers? 1. Please list ALL CURRENT MEDICATIONS, including birth control pills, hormones, and vitamins, herbal medication, diuretics, and weight loss drugs. Include over-the-counter medications. Medication Name Dose Frequency How Long? ALLERGIES:

2. Do you have any MEDICATION ALLERGIES? Yes No Which? 3. Do you have a preferred pharmacy for us to use for any prescriptions: 4. Have you, or any member of your family, ever had any difficulties with any medications, drugs, or gases used for anesthesia? Yes No If yes, when and where? SOCIAL HISTORY: 5. Do you have cocktails regularly, or consume regular amounts of alcoholic beverages, including beer, wine, or other alcohol? Yes No If so, how much? 6. Do you smoke? Yes No If so, how much? For how long? 7. Are you pregnant? Yes No 8. How many pregnancies? Births? Breast Fed? Yes No Recently? RECENT MEDICAL HISTORY: 9. Who is your personal physician, if any? Please list all physicians presently caring for you. 10. Have you ever been under psychiatric care? Yes No When? Why? 11. Is there anything else you think the doctor should know? 12. Please list all SURGERIES AND HOSPITALIZATIONS, including procedures done for cosmetic reasons: SURGERIES When? Why? Your insurance company can be helpful for filling prescriptions Primary Insurance Company: Secondary Insurance Company (if any): Policy Number: Group Number: Insurance Phone contact: Insured name (if other than yourself): DOB: / / Employer: By signing below, I agree that the above information is complete and accurate to the best of my knowledge. Signature: Date:

FREQUENTLY ASKED QUESTIONS REGARDING HIPAA In a constantly changing healthcare environment, SYNERGY PLASTIC SURGERY is committed to educating their patients about healthcare issues that affect them. As a result, they have provided general information about the Health Insurance Portability and Accountability Act (HIPAA) of 1996 for your review. SYNERGY PLASTIC SURGERY is complying with HIPAA regulations and will be happy to answer any additional questions you might have. WHAT IS THE PRIVACY RULE? The Privacy Rule is part of the HIPAA regulation of 1996. The Privacy Rule establishes a federal requirement that Doctors, hospitals or other healthcare providers and health plans obtain a patient s written consent before using or disclosing a patient s personal information to carry out treatment, payment or healthcare operations. WHAT IS PROTECTED HEALTH INFORMATION (PHI)? Protected Health Information (PHI) means any personal health information as defined by law, including demographic information collected by healthcare provider or other entity that could potentially identify the individual. PHI includes all medical records and other individually identifiable health information held or disclosed by SYNERGY PLASTIC SURGERY regardless of how it is communicated (e.g. electronically, written verbally). WHAT IS TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS (TPO)? TPO refers to the treatment, payment or healthcare operations of SYNERGY PLASTIC SURGERY. In other words, SYNERGY PLASTIC SURGERY can use or disclose PHI for performing any activity that it deems necessary to provide quality patient care; ensure that the physician is paid for services; and, operate the business. Some examples of these activities are use of PHI by the physician and clinical staff to treat a patient; use of PHI by the clerical staff to verify insurance information for billing purposes or obtain referrals; and, use of PHI by administrative staff for strategic planning and internal management activities. WHY DO I HAVE TO SIGN A CONSENT FORM? In order to use or disclose your PHI, SYNERGY PLASTIC SURGERY is required to obtain a signed consent form from you to directly treat you or carry out healthcare payment and business related activities. SYNERGY PLASTIC SURGERY is not required to obtain your prior consent in an emergency, when SYNERGY PLASTIC SURGERY is required by law to treat you, or when there are substantial communication barriers. SYNERGY PLASTIC SURGERY reserves the right to refuse to treat you if you do not sign the consent form. WHAT IS THE DIFFERENCE BETWEEN THE CONSENT AND AUTHORIZATION FORMS? In order to use or disclose your PHI for specific purposes, other than direct treatment, payment, or healthcare operations, SYNERGY PLASTIC SURGERY is required to obtain a signed authorization form from you. For example, if you request Synergy Plastic Surgery to disclose PHI to a third party, you must sign an authorization form. This authorization form is more detailed than a consent form and has a specific expiration date. PATIENT RECEIPT OF NOTICE OF PRIVACY PRACTICES SYNERGY PLASTIC SURGERY has provided information regarding the Notice of Privacy Practices. This notice describes the practice s commitment to privacy, my rights to privacy, and how SYNERGY PLASTIC SURGERY may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). By signing this form, I am acknowledging that I have reviewed the Notice of Privacy Practices which explains how my medical and personal information will be used and disclosed. I understand that I am entitled to receive a copy of this document, upon request. Patient Name (Printed) Signature of Patient/Personal Representative Date Relationship to Patient

Fee Policy Acknowledgement: We look forward to planning your surgery with you! In order to assure smooth and timely scheduling and preoperative planning we have the following policies you need to be aware of. Deposit: A deposit is required to initially secure a surgery day. Full payment will be needed to lock the actual surgery date and time. This is due 14 business days before your surgery happens. If you are unable to fully pay for surgery at that time your surgery date will be given to another patient and your deposit will be applied as a cancellation fee. This cancellation fee is nonrefundable and the deposit value is fully forfeited. Full Payment & Surgery Lock Date: Full payment for your surgery is required 14 business days before the operation. There are multiple ways to cover this payment (check, debit, money order, bank check, credit card, care credit). Actual cash is not accepted. Failure to pay for your surgery date at this time will result in loss of the surgery date reservation and forfeiture of your initial deposit. Cancellations of surgery dates within the lock period will result in a forfeiture of 50% of the collected surgeon fees. This late cancelation fee is not refundable. Date Changes: If possible we try to accommodate surgery date changes. These are allowed until 21 business days before your scheduled surgery date. There is a $500.00 fee to change your day. Changes after the lock date are not allowed and are subject to the late cancellation fee. I understand completely the above policy and timeline for the scheduling of my surgery and possible fees for cancellations or date changes. Signature Print Name Date

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