Patient's Name
Street Address
Apt#
City
State
Zip
Home Phone
Cell Phone
Other Phone
Any restrictions for contacting you?
No
Yes
E-mail
Contact Restrictions
Age
Birthdate
SS#
Gender
Female
Male
Marital Status
Single
Married to
Other
PrimaryDoctor Street Address
City
Phone
How did you hear about Dr. Buinewicz? (Mark all that apply)
TV News
TV Ad
Phone Book
Magazine
Newsletter
Seminar
Salon
Web
Friend/Relative
Doctor
Other
If you were referred by a specific person, may we thank them?
Yes
No
Emergency Contact(Not in your household)
Relationship to Patient
Home Phone
Cell Phone
Other Phone
Photo Authorization
I consent to the taking of photos, slides or video footage by Dr. Buinewicz or his designee of me or parts of my body in connection with the plastic surgery procedure(s) to be performed by Dr. Buinewicz or his staff. Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the images may portray features that will make my identity recognizable. I understand that I may refuse to authorize the release of any health information and that my refusal to consent to the release of health information will prevent the disclosure of such information, but will not affect the health care services I presently receive, or will receive, from Dr.Buinewicz or his staff.
Photos WILL NOT be used other then for educational purposes within the office unless otherwise indicated by an additional consent form.
I have read the above Authorization and Release. I am the parent, guardian, or conservator of , a minor. I am authorized to sign this authorization on his/her behalf and I give this authorization as a voluntary contribution in the interest of public education.
Please Read Completely and Sign
I understand that office visit charges are payable on the day service is rendered. I authorize Brian R. Buinewicz, M.D., P C to bill my insurance company for medically necessary services. Regardless of insurance coverage, I am responsible for all bills being paid in a timely manner. I understand that my contract is between Brian R. Buinewicz, M.D., P C and myself.
I hereby authorize direct payment of medical and/or surgical benefits, to include major medical benefits to which I am entitled, Medicare, Private Insurance, and any other health plan to Brian R. Buinewicz, M.D., P C.
In compliance with Medicare regulations we are required to ask the following questions:
Do you or your spouse work for a company that provides you with health insurance?
Are you entitled to Medicare because of a disability or End Stage Renal Disease?
Is the illness or injury the result of an automobile accident or other injury?
Has treatment for the accident or illness been authorizes by the Veteran's Admin.?
Are you entitled to any benefits under the Federal Black Lung Program?
I certify that this information is true and complete to the best of my knowledge.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Acknowledgement of Receipt of Notice and Consent to Use and Disclose Health Information
This acknowledgment of notice and consent authorizes Le Medspa to use and disclose health information about you for treatment, payment, and health care operations purposes.
Notice of Privacy Practices. Le Medspa has a Notice of Privacy Practices, which describes how we may use and disclose your protected health information and how you can access your protected health information and exercise other rights concerning your protected health information. You may review our current notice prior to signing this acknowledgment and consent.
Amendments. We reserve the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain, including information created or obtained prior to the date of the effective date of the change. You may obtain a revised notice by submitting a written request to our Privacy Officer.
Address to Le MedSpa at Buckingham:
3655 Route 202 Georgetown Crossing
Doylestown, PA 18902 Suites 225-230
Telephone: 215-230-4013 Fax: 215-230-4143
I have received the Notice of Privacy Practices for Le Medspa at Buckingham. Le Medspa at Buckingham is authorized to use and disclose health information about (patient name)
for treatment, payment, and healthcare operations purposes consistent with its Notice of Privacy Practices.
MEDICAL HISTORY FORM
Name
Date:
Date of Birth:
Age:
1. Please list all food and drug allergies.
2. Please list all medications you now take (including over the counter meds, i.e. aspirin).
3. Please list all operations you have had.
4. Please list your medical problems.
5. Please list your present height and weight.
CHECK IF YOU HAVE EVER HAD...
Comments
A heart attack
Heart disease
A heart murmur
Chest pain or angina
High blood pressure
A stroke/mini stroke/TIA
Fainting episodes
Epilepsy/seizures/falling out
Shortness of breath when resting
Shortness of breath when climbing stairs or walking
Shortness of breath at night
Asthma/emphysema/COPD-chronic obstructive pulmonary disease
Chronic bronchitis
Tuberculosis
An abnormal chest x-ray (specify)
Diabetes/trouble with your blood sugar
Kidney problems
Arthritis/joint problems
Heartburn/ulcer/hiatal hernia
Cancer (specify)
Chemotherapy (specify)
Liver problems/jaundice/hepatitis
Anemia/iron poor blood/low blood count
Bleeding tendencies
Thyroid problems
A significant weight loss without trying to diet
Mental/emotional/nervous disorders
Eye problems
Frequent headaches/migraines
A problem with anesthesia
Hepatitis
HIV
CHECK TO INDICATE WHETHER YOU CURRENTLY...
Comments
Smoke cigarettes? (specify number of packs per day)
Drink alcohol?
Could be pregnant?
Have a cold or cough?
Have bridgework, dentures, chipped or loose teeth, caps, braces?
Have any physical disabilities?
I certify that the above information is true and correct to the best of my knowledge.