Download Patient Information Form - Plastic Surgery Center of Hampton Roads

Plastic Surgery Center of Hampton Roads Patient Information Form
Patient Name: First: _______________________MI:________ Last: __________________________
Address: _____________________________________City: _______________ST/Zip: ___________
Home Phone: ___________________ Cell: ____________________ Work: ___________________
Social Security #: ___________________ Male / Female Date of Birth: _____________ Age: ______
Email address: __________________________________ Marital Status: _____________________
Employer Name/ Address: ___________________________________________________________
Emergency Contact Name: ________________________________ Phone: ____________________
Primary Care Physician: ______________________ Referring Physician: ______________________
Reason for Visit: ___________________________________________________________________
Is this the result of an injury? Y / N Date of Injury: __________________
Work related? Y / N
 Primary Insurance Company
Name:______________________________________________________________________
Subscriber Name: ________________________________ Subscriber Date of Birth: _____________
Subscriber SS #:_______________________________ Relation to Subscriber: __________________
Policy Number: ____________________________________ Group Number: __________________
 Secondary Insurance Company
Name:_______________________________________________________________________
Subscriber Name: _______________________________ Subscriber Date of Birth: ______________
Subscriber SS #:_______________________________ Relation to Subscriber: __________________
Policy Number: ____________________________________Group Number: ___________________
I consent that photographs may be taken of me or parts of my body as deemed necessary by Plastic Surgery Center of Hampton Roads for
pre and post-operative documentation, and I consent to the release of these photographs for the purpose of judicial cases or insurance
coverage.
I hereby authorize that medical treatment be rendered to me by the Plastic Surgery Center of Hampton Roads. In the event that my
insurance company is billed, I authorize release of information to the insurance companies named above and request that a payment of
medical benefits be paid directly to Plastic Surgery Center of Hampton Roads.
I understand that I will be responsible for any balance left unpaid by my insurance company. I agree to make payments myself if my
insurance company does not pay within a reasonable amount of time. If collection procedures are required and instituted against me, I
agree to pay any and all reasonable costs including collection agency fees, court costs, and attorney’s fees.
Patient Signature: _________________________
Date: ___________
For office use only:
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