THE AESTHETIC SURGERY CENTER pdf

The Aesthetic Surgery Center ™ RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com 1.) How did you hear about The Aesthetic Surgery Center ™ , The Face Spa ™ , Dr. Richard Maloney, and/or Dr. Anurag Agarwal? (select all that apply) 2.) Have you seen any of our advertisements? (select all that apply) 3.) What reason(s) were most important in your decision to make an appointment? (select all that apply) Attended a Seminar Positive Aging Television Show Word of Mouth Take A Look Television Show Referral by a freind Other - Please specifiy Gulfshore Life N Magazine Naples Daily News Ft. Myers News Press Naples Yellow Page Directory Ft. Myers Yellow Page Directory Dr. Maloney's/ Dr. Agarwal's extensive experience and credentials Pricing seemed fair and reasonable The location of The Aesthetic Surgery Center Office staff was knowledgeable and courteous Computer Imaging System Skin care products offered Skin care services offered Referral from someone else Thank you for taking the time to complete our questionnaire Date: Name: Visted aestheticsurgerycenter.com Print Form The Aesthetic Surgery Center ™ RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com Welcome to Our Office OUT OF TOWN ADDRESS: Which surgical procedures are you interested in? (check all that apply) PLEASE PRINT Date Last Name First Name Middle Social Security # (last 4) Date of Birth Height Weight Phone NumberZipStateCityAddress How did you hear about Dr. Maloney or Dr. Agarwal? Zip CodeStateCityAddress Home Phone Cell Phone Sex Martial Status (check one) Male Female SING MAR WID DIV SEP Forehead/Brow Lift Chemical PeelEye Lid Procedure Mid-Face Lift Botox Skincare Lip Enhancement Facial Fillers Lower Face/Neck Lift Laser Wash Rhinoplasty Hair Restoration Other Employer's AddressEmployer Business Phone OccupationSpouse's Name Business Phone Phone Number Relation to the PatientNext of Kin Age Email Address NOYES Did you attend one of our Seminars? Secondary Insurance Company Primary Insurance Company Policy Holder's SSN Policy Holder's Date of BirthPolicy Holder The Aesthetic Surgery Center ™ RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com We request that ALL FEES FOR OFFICE TREATMENT OR CONSULTATION BE PAID AT THE TIME OF VISIT. 2. HAVE YOU SPECIFIC INSTRUCTIONS FOR CONFIDENTIALLY IF WE NEEDTO CONTACT YOU? 3. HAVE YOU EVER CONSULTED A PLASTIC SURGEON? (Please give details) 4. HAVE YOU EVER HAD ANY PLASTIC SURGERY? (Please describe & include dates) 5. WERE YOU SATISFIED WITH THE RESULTS OF ANY PLASTIC SURGERY YOU MAY HAVE HAD? 1. WHAT IS THE PURPOSE OF THIS CONSULTATION? (Please specify) 8. PLEASE LIST ANY SURGERIES YOU MAY HAVE HAD: TYPE DATE SURGEON COMPLICATIONS 7. LAST GENERAL PHYSICIAN EXAM Date Physician Doctor's # 6. HAVE YOU OR AN IMMEDIATE FAMILY MEMBER EVER OR ARE PRESENTLY INVOLVED IN LITIGATION AGAINST A PHYSICIAN OR HEALTH CARE PROVIDER? NOYES The Aesthetic Surgery Center ™ RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com (Please do not omit anything because medications used during and after surgery may interact adversely.) 10. DO YOU HAVE, OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING? (check all that apply) Heart Disease Lung Disease Kidney Disease Liver Disease Thyroid Disease Diabetes High Blood Pressure Cancer Hepatitis Stroke Recent Infection Sickle Cell Disease Anemia Alcoholism Epilepsy Glaucoma Headache HIV Currently Pregnant Mitral Valve Prolapse Problems with Anesthesia Cold Sores Immune Deficiency Bruise / Bleed easy Problems with scars Stomach Ulcers AIDS 11. HAVE YOU EVER RECEIVED TREATMENT FOR A MENTAL CONDITION, EMOTIONAL PROBLEM OR DEPRESSION? (if yes, please explain below) YES NO 9. PLEASE LIST ANY OTHER HOSPITALIZATIONS: 13. WHAT MEDICATIONS ARE YOU CURRENTLY TAKING? MEDICATION DOSAGE FREQUENCY PURPOSE TYPE DATE PHYSICIAN COMPLICATIONS 12. DO YOU, OR HAVE YOU, EVER USED ANY DRUGS FOR RECREATIONAL PURPOSES? THE FOLLOWING MAY INTERACT WITH SOME ANESTHETICS: Do you have any other medical conditions not noted above? (Please explain) Marijuana Cocaine / Crack HeroinLSD / ACID Other The Aesthetic Surgery Center ™ RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com PHYSICIAN NOTES Other Pain Remedies Tetanus / Other Serums Novocaine / Xylocaine Adhesive Tape PhisoHex / Hibiclens Lodine Merthiolate Penicillin Other Antibotics Morphine / Codeine Demerol / Other Narcotics Other Anesthetics Aspirin / Empirin Other Any Inhalant Allergies Latex Other Antiseptics Any food Allergeries 14. HAVE YOU EVER HAD A BAD REACTION OR ALLERGIC REACTION TO ANY OF THE FOLLOWING? (If you answer yes to any, please explain in detail) 19. IS THERE ANYTHING YOU WISH TO TELL DR. MALONEY AND/OR DR. AGARWAL THAT YOU DO NOT WISH TO INCLUDE ON THIS FORM? YES NO 18. IS THERE ANYONE IN YOUR LIFE WHO ENCOURAGES OR DISCOURAGES YOUR CHOICE TO UNDERGO PLASTIC SURGERY? (if yes, please explain below) YES NO YES NO 15. DO YOU CURRENTLY SMOKE? DID YOU EVER SMOKE? NOYES IF YES TO EITHER QUESTION, PLEASE ANSWER How many years? Number of packs per day? If yes, when did you quit? 16. IS THERE A CHANCE THAT YOU MAY BE PREGNANT OR BECOME PREGNANT WITHIN THE NEXT 6 MONTHS? (if yes, please explain below) NOYES NA 17. DO YOU CONSUME ALCOHOL? NOYES If yes, glasses of per The Aesthetic Surgery Center ™ RICHARD W. MALONEY, M.D., F.A.C.S. & ANURAG AGARWAL, M.D., F.A.C.S. THE PHYSICIANS BUILDING, SUITE # 1115 ~ 11181 HEALTH PARK BLVD ~ NAPLES, FLORIDA 34110 800.594.7472 ~ 239.594.9100 aestheticsurgerycenter.com Photographs & Computer Imaging Payment Information I HEREBY AUTHORIZE PAYMENT DIRECTLY TO The Aesthetic Surgery Center, for the surgical benefits AND major medical benefits if otherwise payable to me under the terms of my insurance. A deposit of 25% (twenty-five percent) of the total procedure cost is required to schedule a cosmetic procedure. The Aesthetic Surgery Center must receive full payment 14 (fourteen) days prior to the scheduled date of the cosmetic procedure. A cancellation fee of 10% (ten percent) of the total procedure cost is assessed if the procedure is cancelled more than 14 (fourteen) days prior to the scheduled date of the cosmetic procedure. However, a cancellation fee of 25% (twenty-five percent) is assessed if the procedure is cancelled on or within 14 (fourteen) days of the date of the scheduled cosmetic procedure. In the event that the procedure is cancelled and re-scheduled, it is at the sole discretion of The Aesthetic Surgery Center to assess the full corresponding cancellation fee or a portion of it, or waive the cancellation fee all together. Any balances that remain following the cosmetic procedure, must be paid in full within 30 (thirty) days from the date of service. All balances that remain after 30 (thirty) days from the date of service will be assessed a late fee of 10% (ten percent) of the outstanding balance. Additionally, finance charges of 12.00% compounded monthly (12.6825% APR) will be applied on the outstanding balance. You agree to pay any and all late fees, finance charges, and collection fees, including reasonable attorney’s fees, that may be incurred from failure to pay the outstanding balance. I hereby authorize The Aesthetic Surgery Center to release any information acquired in the course of my examination or treatment to attorneys, physicians, and/or insurance companies. I have read the above and fully understand its implications. I hereby agree to these terms in full and do hereby give my consent and permission to allow Dr. Maloney and/or Dr. Agarwal to examine me, and if necessary to provide medical care in the specialty of Facial Plastic and Reconstructive Surgery. It is our policy that ALL NEW patients be photographed for computer imaging purposes. It is an essential part of the initial consultation, analysis and discussion of possible treatment options. Additional photographs may be required before and following any surgical procedures. Computer imaging is provided so our patients can view a computer enhanced photo of themselves. This service is provided for simulation purposes only. The Aesthetic Surgery Center does not guarantee surgical results and your results may vary. Dr. Maloney, Dr. Agarwal, and the staff of The Aesthetic Surgery Center are committed to maintaining patient confidentiality. We will keep all of your information and digital photography private. Prior to using your information for educational and/or marketing purposes, The Aesthetic Surgery Center will obtain additional consent. The photograph shall become the property of The Aesthetic Surgery Center, and will be available to you under the guidelines of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), Privacy Regulations. Date Witness's Signature Patient's Signature (Parent, Guardian, or Custodian, if a minor) . marketing purposes, The Aesthetic Surgery Center will obtain additional consent. The photograph shall become the property of The Aesthetic Surgery Center, and. else Thank you for taking the time to complete our questionnaire Date: Name: Visted aestheticsurgerycenter.com Print Form The Aesthetic Surgery Center ™ RICHARD