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2013 registration

PATIENT REGISTRATION
Use black ink
Ricardo Izquierdo, M.D.
Plastic Surgery & Advanced Medical Services Date____________________Name_____________________________________ Address_________________________________________ City________________________ State________________ Zip______________ Date of Birth________________ Age______ Sex_______ Email__________________________________Social Security #__________________________ Marital Status______________Home Phone________________________ Work Phone_____________________ Referring Doctor_________________________ Other Source  internet  ad  phone book  patient Employer/School Name________________________________________________________ Employer/School Address______________________________________________________ City________________________ State_________________ Zip_____________ Nearest Relative/Friend(not in household)________________________________________ Address_______________________________________ Phone_______________City______________________ State________________ Zip____________ PHYSICIAN INFORMATION
Family Physician________________________________Address______________________________________
City______________________________State________Zip____________Phone_________________________
COMPLETE IF PATIENT IS A MINOR AND/OR RESPONSIBLE PARTY
Father’s Name_____________________________________ SS#_________________ Phone_____________
Address___________________________________ City____________________ State_____ Zip___________
Mother’s Name_____________________________________ SS#_________________ Phone_____________
Address___________________________________ City____________________ State_____ Zip___________
INSURANCE INFORMATION
Employer___________________________________________________________________________________
Primary Insurance______________________________ Address______________________________________
City______________________________ State________ Zip____________
Policy Holder____________________________ Group #___________________ Plan #____________________
Date of Birth (policy holder) ___________________ ID/Social Security # (policy holder)____________________
ALL OTHER INSURANCE INCLUDING SUPPLEMENT TO MEDICARE
I authorize the above physician to release any information regarding service rendered by him/her and allow a photocopy
of my signature to be used to file insurance. I hereby assign, transfer, and set over any benefits payable by my
insurance carrier(s) to the above named physician/physicians for services rendered, regardless of my insurance
benefits, if any. I understand I am financially responsible for the fees for services rendered.
I authorize the release of any medical information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment on services provided to me.
MEDICAL HISTORY
Reason for Appointment______________________________________________________________________Height _______ Weight______ Are you pregnant or lactating? Yes  No  Past Medical History
Previous Services
 ALS (Lou Gehrig’s Disease)  Laser Treatments Past Surgical History________________________________________________________________________Allergies___________________________________________________________________________________LATEX Allergy yes  no Malignant hyperthermia yes no Current Medications_________________________________________________________________________  Coumadin®  Aleve®  Celebrex®  Herbal/Vitamins____________________________________________________________________ Alcohol Use yes  no  Frequency/Amount_______________________________________________Smoker yes  no Date of last menstrual period___________________________ Date of last PAP smear____________________Date of last tetanus___________________________________ Date of last mammogram__________________ MEDICAL PHOTOGRAPHS
Photographs may be taken during the course of my treatment in order to demonstrate my condition or disorder, and subsequent therapy.
I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health I wil report it to the office as soon a possible. I understand that results are individual and the success of a treatment program varies with each person. I acknowledge that al answers have been recorded truthful y and wil not hold any staff member responsible for any errors or omissions that I have made in the completion of this form. I understand that I am financial y responsible for the fees for services rendered.
_____________________________________________________ _______________________________Signature of patient (or authorized person) date

Source: http://www.napervilleplasticsurgeon.net/wp-content/uploads/2013/07/2013-Registration.pdf

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