New Patient Information

 Male Female

Select a country:
—United StatesUnited KingdomAustraliaCanadaFranceNew ZealandIndiaBrazilAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosDemocratic Republic of the CongoRepublic of the CongoCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNetherlandsNetherlands AntillesNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands BritishVirgin Islands USYemenZambiaZimbabwe

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 Home Work Cell Other

May we:

 Yes No

 Yes No

 Yes No

 Yes No

 Yes No

Select a country:
—United StatesUnited KingdomAustraliaCanadaFranceNew ZealandIndiaBrazilAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosDemocratic Republic of the CongoRepublic of the CongoCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNetherlandsNetherlands AntillesNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands BritishVirgin Islands USYemenZambiaZimbabwe

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I VERIFY THAT THE ABOVE INFORMATION IS CORRECT. I AUTHORIZE RELEASE OF MY MEDICAL INFORMATION TO MY INSURANCE CARRIER AND AUTHORIZE PAYMENT DIRECTLY TO MY PHYSICIAN. IT IS UNDERSTOOD THAT MY PHYSICIAN IS NOT RESPONIBLE FOR COLLECTING INSURANCE BENEFITS OR NEGOTIATING THE SETTLEMENT OF A DISPUTED CLAIM. THE UNDERSIGHNED IS RESPONSIBLE FOR PAYMENT OF ALL CHARGES INCURRED, REGARDLESS OF ANTICIPATED INSURANCE COVERAGE.

Historical Data Sheet

Age*

Height*

Weight*

Reason(s) for seeing physician:*

 Yes No

 Rhinoplasty (nose) Forehead lift Removal of cysts, moles, etc FotoFacial RF Face or Neck Lift Collagen/Botox/Restylane Eyelids Scar Revision Liposuction Protruding ears Skin Resurfacing Skin Care Hair Removal Skin Cancer Lip enhancement Other

 Yes No

If so, whom?

 Botox Cosmetic or Dysport  Injectable Filler Ultherapy Laser Treatments Chemical Peels Customized Facial Laser Hair Removal Skin Care Products CoolSculpting Mineral Make-up 

Please list all medications, vitamins, or supplements you are currently taking (include birth control pills or other homones): *

 Yes No

 Yes No

If drug allergies, please list:

Regarding drug allergies, if any, please list reaction(s):

Previous surgeries (including cosmetic):

Were there any complications to any of the above mentioned procedures? If so, please describe:

Personal Physicians

Family doctor/Internist

City

State

When was your last physical examination?

 Yes No

 Yes No

If so, please provide name

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Please check the appropriate responses for the following “Yes” / “No” questions in this section

 Yes No

If so, please describe:

 Yes No

If stopped, when?

 Yes No

 Yes No

Tobacco use? Amount?

 Yes No

If stopped, when?

# per day:

Alcohol use: Amount?

Are you currently or have you ever been treated or diagnosed for any of the following? (Please mark all that apply).

 Rheumatic Heart Thyroid disorder/ Goiter Diabetes Poor circulation Heart murmr Angina/Chest pain Heart attack High Blood pressure Stroke Headaches/Migraines Chronic Fatigue Fibromyalgia Latex allergy Cold Sores/Fever blisters Kidney Disease Asthma Hay fever/ Nasal allergies Lung/Chest problems Hernia Ulcers Arthritis Lupus/ Scleroderma HIV/AIDS Gall bladder disorders Depression Nervous breakdown Psychiatric or “nerve” problems Seizures/ Convulsions Anemia Bleeding tendencies Scarring Staph Infection Vision changes Eye problems Skin Conditions (irritation/rashes/infections) Alcohol Recreational Drugs Paralysis/ Numb Bell’s Palsy Easy Bruising Fibrocystic disease

 Hepatitis Jaundice Neither

 A B C Not applicable

 Yes No

 Skin Other

If other, which type:

 Yes No

If so, please explain:

 Yes No

 Yes No

Please list any other additional information you think or would be important for us to know about your medical or social history prior to your surgery. Do you have any specific or unique questions you want answered?

Confidiential Record:

Information contained here will not be released except when you have authorized us to do so. Please answer all questions to the best of your knowledge. The information provided by you will be used by your doctor in making decisions regarding your care.

I authorize my physician and/or administrative and clinical staff to telphone or otherwise contact me (or the responsible party) regarding appointments, treatment information, or any other details related to patient therapy and treatment.

Patient Financial Responsibility

Patient Financial Responsibility:

I accept financial responsibility for any products or services rendered by any employee of Rejuvenis Facial Cosmetic Surgery & Medical Spa. If a claim is submitted to my insurance company, I accept financial responsibility for any portion not covered by my insurance. If it becomes necessary for Rejuvenis Medical Spa to pursue collections, I agree to be responsible for any costs associated with collection, including, but not limited to court costs and reasonable attorney’s fees. I further understand that there is a $27.50 fee for any returned check.

Informed Consent for Patient Computer Imaging

AND AUTHORIZATION FOR RELEASE AND USE OF PHOTOGRAPHS

In the course of consultation and discussions with certified medical professionals, I may have been shown, or may be shown or provided certain brochures, pictures of actual patients or pictures on an electronic computer imaging device. I do understand that those pictures and alteration of these pictures seen are solely for the purpose of illustration, discussion, and to provide improved communication with medical professionals. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics and health. I further understand and acknowledge that because of the obvious significant differences in how living tissues react to surgery, there may be no relationship between the electronic images created, and my actual final surgical result. Use of the computer imaging system offers an opportunity for me to discuss my desires and to allow improved communication with the medical staff.

I certify my understanding that there is no warranty, expressed or suggested, as to my own final appearance after elective surgery by the use of these electronically altered images.

I hereby grant permission and the unrestricted right for the use of any illustrations, photographs or imaging records created in my case for general information, education, public relations purposes, use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity.

I acknowledge that I relinquish all rights, title, and interest in these photographs and/or images, or any right to profit or gain directly or indirectly realized through the use of the photographs/images.

I further certify that this consent can only be revoked in writing and delivered to the physician and will not automatically expire or be revoked by implication. Such revocation shall thereafter be effective as to any further use not already committed to by the physician. Unless earlier revoked, this authorization will expire on the end of the treating physician’s practice of facial and reconstructive surgery, except there will be no expiration for the purpose of medical or scientific research. Revocation will not affect uses and disclosures made before receipt of the revocation. If the photographs are disclosed, there is obviously potential for re-disclosure some of which would not be subject to this authorization. This authorization is in consideration of services performed and consultations conducted or to be performed or conducted by the physician, and there have been no representations or inducements concerning this authorization except as set forth herein. The treating physician will not condition treatment on whether the individual signs this authorization, but, if any portion of the treating physician’s services is to be covered under any insurance or third-party payment plan, the signing individual will be responsible for authorizing release as required by that insurance or third-party payment plan.

AUTHORIZATION BY PARENT OR GUARDIAN

Notice of Privacy Practices

The Federal Government published a rule regarding the privacy of protected health information. The Health Insurance Portability and Accountability Act (HIPPA) established privacy standards that govern organizations like Rejuvenis Facial Cosmetic Surgery & Medical Spa. Rejuvenis Facial Cosmetic Surgery & Medical Spa uses health information for treatment, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you receive.

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about something in this notice please ask the receptionist.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4/14/2003.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

Uses and Disclosures of Health Information

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use your medical information to provide you with medical treatment or services. We may disclose your medical information to other physicians who are also caring for you.

Payment: We may use or disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use or disclose your medical information for office operations. These uses and disclosures are necessary to run the office and make sure that all our patients receive quality care. This means we may use your medical information to review treatment and care you receive from our staff.

Appointment Reminders, Results and Statements: We may use or disclose your healthcare information to provide you with appointment reminders, test and pathology results and statements as long as they are marked personal and confidential. We may send postcards and leave messages at your home and on your answering machine.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal official health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Patient Rights

Right to Inspect and Copy: You have the right to inspect and obtain a copy of your medical information. Usually, this includes medical and billing records.

Right to Amend: If you feel the medical information we have about you is incorrect, or incomplete, you have the right to ask us to amend the information. Amending the information means adding to the information with which you disagree. It does not include deleting, removing or otherwise changing the content of the record. You have the right to request and amendment for as long as the information is kept by or for the office. You may request an amendment in writing to the Privacy Officer at the office address.

Right to Disclosure of Accounting: You have the right to receive a list of disclosure we made of your medical information. This does not include certain disclosures such as those made for the purpose of treatment, payment, healthcare operations or those you have authorized. It also does not include anything before the effective date of this policy (4/14/2003).

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or certain location. (Example: We can only call or contact you at home and not at work.) There are certain people who may call us concerning your healthcare to which we may talk with.

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Officer at the office address.

Rejuvenis Facial Cosmetic Surgery & Medial Spa are required by law to notify you of our privacy practices. This document serves as our notice to you. To acknowledge that you have received this notice please sign this form and return it to the office.

Please complete this section if you are over the age of 18 or an emancipated minor and would like the staff of Rejuvenis Facial Cosmetic Surgery & Medical Spa to discuss any aspect of your medical treatment with the persons below (includes spouse, parents, children, significant other, etc.). Otherwise we will only be able to speak with you about your lab or pathology results or other health issues or questions.