MEDICAL /HISTORY REGISTRATION FORM **PLEASE PRINT** Insurance Information (If this is cosmetic, please disregard this section)
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- Elinor O’Brien’
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1 Date: Sex M F **PLEASE PRINT** Insurance Infrmatin (If this is csmetic, please disregard this sectin) Patient Name: Address: City: State: Zip: SS#: Hme Ph: Cell: Are yu emplyed? Self Emplyed Retired Name f Emplyer: Type f Occupatin: Marital Status: Married Single Divrced Widwed Primary: Member ID: Ph: Name f Insured: Relatinship t Patient: Secndary: Member ID: Ph: Name f Insured: SSN: SSN: Gp: Gp: Spuse Name: In Case f Emergency, Cntact: Name: Hme Ph: Cell: Wrk: Relatinship t Patient? Hw Did yu hear abut us? Tertiary: Plicy: Ph: Name f Insured: Gp: SSN: Wh is Respnsible fr this accunt? Signature Insurance Assignment And Release I certify that I have insurance cverage with and assign direct payment t Nirvana Plastic Surgery, PA fr insurance benefits n services rendered. I understand that I am financially respnsible fr all charges whether r nt paid by insurance. I authrize the use f my signature n all insurance submissins. The abve named practice may use f my health care infrmatin and may disclse such infrmatin t the abve named insurance cmpany(ies) and the agents fr the purpse f btaining payment fr service and determining insurance benefits r the benefits payable fr related services. Medicare Authrizatin I request that payment f authrized Medicare benefits and, if applicable Medigap benefits, be made n my behalf t Nirvana Plastic Surgery, PA fr service furnished t me by that prvider. Signature f Patient, Parent r Guardian Date 1
2 Cardivascular A fib Anemia Aneurysm Bleeding Disrder Cartid Artery Disease Edema Endcarditis Heart Disease High Lw Bld Pressure High Chlesterl Hyperlipidemia Irregular Heart Rate Mitral Valve Prlapse Mycardial Infarct/Heart Attack Pace Maker Peripheral Vascular Disease Plycythemia Vera Syncpe and Cllapse Tachycardia Cnnective Tissue/Aut Immune Aut Immune Disease Cnnective Tissue Disease Lupus Plychndritis Raynaud's Disease Rheumatic fever Rheumatid Arthritis Sarcidsis Sjögren's Syndrme Digestive/Gastrintestinal Appendicitis Blating/Cnstipatin C Diff Cln Cancer Crhn's Disease Diverticulsis Gall Bladder Disease Gallstnes Gastritis Gastrintestinal Bleeding GERD Hiatal Hernia IBS Intestinal Disease Liver Disease Stmach Ulcers Ulcerative Clitis PLEASE CHECK ALL OF THE FOLLOWING THAT APPLY: Endcrine Diabetes Hyperglycemia Hyperthyrid Hypthyridism PCOS Thyrid Mass Thyrid Prblems Eyes,Ears,Nse, Thrat Blurred Visin Cataracts Glaucma Hearing Lss Pst Nasal Drip Geniturinary BPH Dialysis Endmetrial Cancer Hrmne Replacement Therapy Kidney Disease Prstate Prblem STD/Veneral Disease Urinary Retentin Infectins Chicken Px Hepatitis A B C Herpes/Cld Sres HIV MRSA Mumps Pli Sepsis Shingles Typhid Fever Lymphatic Lymphma Musculskeletal Arthritis Back Pain Degenerative Disc Disease Fibrmyalgia Gut Herniated Disc Neck Shulder Pain 2 Musculskeletal (cntinued) Ostepenia Osteprsis Restless Legs Syndrme Neurlgical ADHD Alzheimer's Disease/Dementia Anxiety Bell's Palsy Biplar Disrder Brain Tumr Chemical Dependency Chrnic Pain Syndrme Depressin Dysthymia Epilepsy Erb's Palsy Hemiparesis/Paralysis Headaches Hydrcephaly Migraine Neurpathy RSD/Pain Disrder Sciatica Seizures Spina Bifida Tremrs Visual Hallucinatins Respiratry Asthma COPD Emphysema Lung Cancer Measles Multiple Sclersis Pneumnia PTSD Seasnal Allergies Sleep Apnea Strke Trachemalacia Tuberculsis Skin/Breast Acne Benign Breast Cyst/Mass Breast Cancer Breast Mass Cystic Acne Kelids Nn healing wund Skin Cancer Other cancers: WOMEN ONLY: Abnrmal pap smear Bleeding between perids Breast Augmentatin Breast Lump Extreme menstrual pain Nipple discharge Other : Are yu pregnant? Are yu currently breastfeeding? Prir pregnancies? Did yu breastfeed? Date f last mammgram: Abnrmal Mammgram Results: Where was yur Mammgram perfrmed? Date f last menstrual perid: Date f last Pap smear:
3 PRIMARY CARE PHYSICIAN INFORMATION Primary Physicians Name: Facility Name: Physicians Ph: Date f Last Exam: FAMILY HISTORY Has anyne in the family experienced any f the fllwing? RELATION RELATION Allergies Lung Cancer Alzheimer's/Dementia Lung Disease Aneurism Lymphma Arthritis Mental Illness Asthma MRSA Aut Immune Disease Migraine Headaches Bleeding Disrders Ovarian Cancer Bld Clts Pneumnia Brain Tumr Prstate Cancer Breast Cancer Reactin t Anesthesia Cervical Cancer Renal Failure Cln Cancer Sepsis Cngestive Heart Failure Seizures/epilepsy COPD Skin Cancer Diabetes Strke Emphysema Thyrid Disease Fibrmyalgia Tuberculsis Gastrintestinal Bleeding UHL Disease Gut Nn cntributry Heart Disease Other: Leukemia Liver Cancer SOCIAL HISTORY Check which nes yu use and hw much: Alchl Use: Greater than 1 daily Less than 1 Daily Nne Caffeine: 1 2 Daily Greater than 2 daily Nne Exercise: 3 5 times Weekly Daily Once Weekly Nne Recreatinal Drug Use: N Yes: Smking Status: Current every day smker Current sme day smker Frmer smker Never smker 3
4 HOSPITALIZATION HISTORY Have yu ever been hspitalized? See List (Please include date and facility) SURGICAL HISTORY Have yu ever had surgery? See List (Please include date and facility) HAVE YOU EVER EXPERIENCED ANY COMPLICATIONS WITH ANESTHESIA? If yes, Please Explain: MEDICATIONS/ALLERGIES Pharmacy Name: Street, City: Ph: List medicatins, vitamins r supplements yu are currently taking: (r yu may prvide a list) **Please include dsage** Are yu allergic t any medicatins r substances? *Please list reactin* N Knwn Medicatin Allergies N Nn Medicatin Allergies Reactin: Severity: Mild Mderate Severe Reactin: Severity: Mild Mderate Severe Reactin: Severity: Mild Mderate Severe T the best f my knwledge, the abve infrmatin is cmplete and crrect. I understand that it is my respnsibility t infrm my dctr if I, r my minr child ever have a change in my/child health r insurance infrmatin. Signature f Patient, Parent r Guardian Relatinship t Patient: Date: 4
5 Hw May We Cntact Yu? (Please check all that apply) What is yur preferred methd f cmmunicatin? Hme Cell Wrk Hme Phne: ( ) Cell: May we leave a vic ? May we leave a message with anther persn? ( ) May we leave a vic ? May we leave a message with anther persn? Is it OK fr us t text yu: An Appintment Reminder Medical r Scheduling Inf Special Offers Wh is yur cell phne prvider? AT&T Sprint T Mbile Verizn Other: Wrk Phne: ( ) Is it OK fr us t yu: An Appintment Reminder Medical r Scheduling Inf Special Offers 5
6 ***MISSED APPOINTMENT/LATE CANCELLATION POLICY*** We wuld like t thank yu fr chsing us yur prvider f medical and aesthetic services. In rder t give yu and all f ur patients, the best pssible care/service, we request that yu review ur plicy regarding missed appintments and late cancellatins. A missed appintment is when yu fail t shw up fr an alltted appintment time, withut a phne call. A late cancellatin is when yu fail t give a ntice f at least 24 hurs prir t yur scheduled appintment time. Please remember that we have reserved appintment times t accmmdate yur schedule. Therefre, we respectfully request at a 24 hur ntice in rder t reschedule yur appintment. This will enable us t ffer yur cancelled appintment time t ther patients. If yu are unable t keep yur scheduled appintment time, please cntact ur ffice at (843) at least 24 hurs in advance in rder t avid a missed appintment/late cancellatin fee. This charge is nt cvered by yur insurance carrier. If yu fail t give us ntice f yur missed appintment r yu cancel with less than a 24 hur advance ntice, yu will be charged a $50 missed appintment/late cancellatin fee. I have read and understand the plicy stated abve. Signature Date 6
7 Acknwledgement f Receipt f Ntice f Privacy Practices (Yu May Refuse t Sign this Acknwledgement) I,, have received a cpy f this ffices Ntice f Privacy Practices. Please Print Name Signature Date Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatin barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other specified reasn Emplyee Signature Date 7
**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
Patient Infrmatin Tday s date: Patient Name: I prefer t be called Last First MI Address: Street Apartment # City State Zip Cde Sex: Male Female Check ne: Minr child** Single Married/Partnered Patient s
EAST VALLEY DERMATOLOGY CENTER
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Address: City: State. Phone: (Home) (Work): (Cell): Age Date of Birth / / Occupation. Referred by: Patient s condition: Duration of Problem:
Patient s Last Name: First Name: Address: City: State Zip Phne: (Hme) (Wrk): (Cell): Age f Birth / / Email: Occupatin Referred by: Patient s cnditin: Duratin f Prblem: Dctr: Dctr s Telephne: N. in husehld
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Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
Patient Health History
Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Female Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719 2441 / Fax (724)719 2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn
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