New Patient Information

Preferred contact * Home Work Cell Other

How did you hear about us?

May we:

LEAVE A DETAILED MESSAGE AT YOUR HOME (VOICEMAIL/PERSON)?* Yes No

LEAVE A DETAILED MESSAGE ON YOUR CELL VOICE MAIL?* Yes No

SEND YOU A DETAILED MESSAGE VIA EMAIL?* Yes No

SEND YOU A REJUVENIS PROMOTIONAL EMAIL?* Yes No

A DETAILED MESSAGE WOULD TYPICALLY CONSIST OF THE PRACTICE NAME AND/OR YOUR PHYSICIAN’S NAME, AS WELL AS SPECIFIC INFORMATION PERTAINING TO YOU OR REQUESTED BY YOU. IT MAY ALSO CONTAIN QUESTIONS WE NEED YOU TO ANSWER REGARDING YOUR CARE OR YOUR ACCOUNT.

Person to contact in case of emergency *

Patient Financial Responsibility

I VERIFY THAT THE ABOVE INFORMATION IS CORRECT. THE UNDERSIGNED IS RESPONSIBLE FOR THE PAYMENT OF ALL CHARGES INCURRED.

I accept financial responsibility for any products or services provided by Rejuvenis Facial Plastic Surgery and Medical Spa

I agree to be responsible for any costs associated with collection of past due or unpaid fees, including but not limited to court costs and reasonable attorney’s fees.

I further understand that there is a $30 fee for any returned check.

We request a minimum of two business days’ notice for cancellation of a scheduled appointment. Understand that when you do not show up for, or cancel an appointment on short notice, it prevents us from utilizing our valuable time and prevents other patients from receiving care. We reserve the right to assess a “no-show” fee for patients who do not show up for their appointment, or for last-minute cancellations. Habitual no-show or short notice cancellations may result in a denial of service at Rejuvenis. Urgent or emergency medical care will not be denied in any circumstances.

Fees for “no show” appointments or cancellations within two business days are as follows:

• Dr. Russo and nurse injector: $150 for consultations and/or scheduled injectable appointments.
• Medical Spa: $75 for consultations or 50% of scheduled treatment cost.

A scheduling deposit of 20% is required for certain procedures which are associated with longer treatment times and greater commitment of resources. This deposit is nonrefundable in instances where the patient does not show up for their appointment or cancels with less than two business days’ notice for any reason other than an emergency.

REFUNDS:

Services at Rejuvenis are offered by Dr. Russo and his staff in good faith after thorough evaluation and assessment of a patient’s concerns. While it is impossible and unethical to guarantee results in a medical/surgical encounter, what we do offer is a good faith commitment to provide a thorough, expert, and honest evaluation of, and best effort treatment of a patient’s concerns. To that end, we commit to working with our patients to achieve their desired results, but do not offer refunds of fees for services rendered.

Date:

Print Name Date:

Patient or Guardian Signature * Date: *

Historical Data Sheet

Age*

Height*

Weight*

Reason(s) for todays visit:*

Which procedure(s) are you interested in?

Injectable Treatment / Botox® / FillerPhotoFacialFace or Neck RejuvenationEyelidsChinSkin ResurfacingLip EnhancementHair RemovalRemoval of cysts, moles, etc.Neck LiposuctionScar RevisionSkin Care

Other

Have you consulted another doctor in regards to this type of procedure? Yes No

If so, whom?

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

Add More

Are you allergic to Latex? Yes No

Previous Cosmetic Procedures (Past 5 years)

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

Please check the appropriate response

Have you ever had any reaction to local or IV Sedation Medication? Yes No

If so, please describe:

Ever taken Accutane? Yes No

If stopped, when?

Take aspirin or any blood thinning medication/supplements regularly?
Prescription/Non Prescription (Aspirin, Ibuprofen, ect) Yes No

Tobacco/Nicorette/Nicotine patches Yes No

Amount per

Do you bruise easily? Yes No

Alcohol use? Yes No

Amount per

Recreational Drugs Yes No

Type Amount

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

Check All That Apply

Are you being treated or have you been treated for cancer?
Yes No

Have you been treated for any psychiatric or mental illness? Yes No

Do you have any other medical problems that have not been covered? Yes No

If so, please explain:

Do you realize every procedure is followed by a period of healing (eg. swelling, bruising) before the tissue returns to normal and a final result is apparent?
Yes No

Do you understand that the objective of any cosmetic procedure is improvement in appearance, not perfection?
Yes No

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

Confidential 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 telephone or otherwise contact me (or the responsible party) regarding appointments, treatment information, or any other details related to patient therapy and treatment.

Electronic Signature: * Date:*

Notice of Privacy Practices

Effective April 14, 2003

The Federal Government published a rule regarding the privacy of protected health information. The Health Insurance Portability and Accountability Act (HIPAA) 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 authorize 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.

PLEASE COMPLETE THIS FORM AND RETURN IT TO THE OFFICE AT YOUR EARLIEST CONVENIENCE:

Rejuvenis Facial Cosmetic Surgery & Medical Spa is 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.

Electronic Signature of Patient or Legal Guardian * Date:*

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 (including 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.

Authorized Name

Relationship