New-patient-form_rev05

ASSOCIATES IN PLASTIC AND RECONSTRUCTIVE SURGERY, PC PATIENT INFORMATION
Dr. Eyssen Dr. vonWerssowetz Dr. Chase Name:________________________________________________________________________________________________ Address: ______________________________________________________________________________________________ City: ________________________________ State: __________________________ Zip: __________________________ Home Phone __________________________ Work Phone: ____________________ Cel Phone: ____________________ Social Security Number: ________________ Date of Birth: __________________ Age: Sex: ❏ Male ❏ Female E-mail Address: ________________________________________________________________________________________ Occupation: ________________________________________ Employer Address: __________________________________ SPOUSE OR PARENT INFORMATION
Spouse/Parent’s Name: ______________________________ Social Security Number:______________________________ Spouse/Parent’s Employer: ____________________________ Address: __________________________________________ Spouse/Parent’s Phone: ______________________________ Nearest Relative Outside Household: ______________________________________________________________________ Relationship to the Above: ____________________________ Phone: ____________________________________________ INSURANCE INFORMATION
Primary: __________________________________________ Secondary: ________________________________________ Group/Employer:____________________________________ Group/Employer: __________________________________ Date of Birth of Insured: ______________________________ Date of Birth of Insured:______________________________ ID Number: ________________________________________ ID Number: ________________________________________ Group Number: ____________________________________ Group Number: ____________________________________ Deductible: $ ____________________________________.00 Deductible: $ ____________________________________.00 If Accident, Date of Injury: ______________________________________________________________________________ Worker’s Comp: ____________________________________ Auto Acc: ________________________________________ Patient!Name____________________________________________________!!Date!of!Birth_______________________ Age__________!!Weight__________!!!Height__________!!!Reason!for!Visit_____________________________________ Primary!Care!Dr._________________________________!!!!Referring!Dr!or!Person_______________________________ Prescription!Medication______________________________________________________________________________ __________________________________________________________________________________________________ Vitamins/Herbs/Over#the#Counter!Medication____________________________________________________________ Please!check!if!appropriate.!!Do!you!take:!!!!!!!Aspirin!!!□ !!!!!!Fish!Oil!!!□!!!!!Diet!Pil s!!!□ Allergies___________________________________________________________________________________________ Previous!Hospitalizations______________________________________________________________________________ Number!of!Pregnancies________________________________ Number!of!Children____________________________________ Did!you!breast!feed?___________________________________ Date!of!Last!Mammogram____________________________ Have!you!had!any!surgery!on!your!breasts?_________________________________________ Previous!Surgeries!___________________________________________________________________________________ ASSOCIATES IN PLASTIC AND RECONSTRUCTIVE SURGERY, PC PHOTOGRAPHIC AUTORIZATION AND RELEASE
I, _______________________________________ , authorize Associates in Plastic and Reconstructive Surgery, PC and/or hisrepresentative(s), to take photographs.
In addition, I authorize the use of these images, without compensation to me, for the fol owing specific purposes: (Please initial in the boxes marked Yes or No for each item) in the office photo album for prospective patients.
in our website for prospective patients.
in print advertisements.
on television.
I may refuse to sign this authorization without such refusal affecting the medical treatment I receive from Associates in Plasticand Reconstructive Surgery, PC.
Signature ____________________________________________________________________ Date __________________ PRIVACY POLICY
I understand I have a right to review Associates in Plastic and Reconstructive Surgery, PC's Notice of Privacy Practices prior tosigning this document. The Associates in Plastic and Reconstructive Surgery, PC's Notice of Privacy Practices has been provided tome. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that wil occurin my treatment, payment of my bil s or in the performance of health care operations of the Associates in Plastic and ReconstructiveSurgery, PC. This Notice of Privacy Practices also describes my rights and the Associates in Plastic and Reconstructive Surgery,PC's duties with respect to my protected health information.
Associates in Plastic and Reconstructive Surgery, PC reserves the right to change the privacy practices that are described in theNotice of Privacy Practices. I may obtain a revised notice of privacy practices by cal ing the office and requesting a revised copybe sent in the mail or asking for one at the time of my next appointment.
Signature ____________________________________________________________________ Date __________________

Source: http://www.aprs.md/wp-content/uploads/2012/04/New_Patient_Form_rev06.pdf