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BOSTON PLASTIC SURGERY ASSOCIATES
BOSTON MEDICAL AESTHETICS
DR. BROOKE R. SECKEL
DR. SEAN T. DOHERTY
JOHN CUMING BUILDING
131 ORNAC SUITE 700
CONCORD, MA 01742
PHONE: 978-369-4499
FAX: 866-743-7213
DATE: ________________
PURPOSE OF VISIT: ________________________
INTAKE FORM
PATIENT CONTACT
EMERGENCY CONTACT
Emergency Contact: ______________________
First Name: _______________________
Relationship: ___________________________
Middle Name: ____________________
Home Phone: ___________________________
Last Name: _______________________
Work Phone: ___________________________
Street: ___________________________
Mobile Phone: __________________________
___________________________
First Contact #: __________________________
City: ____________________________
State: ___________________________
PATIENT INFORMATION
Zip Code: ________________________
Date of Birth: ___________________________
Country: _________________________
Gender:
M ___
F ___
Social Security #: __________________
Height: ________________________________
Home Phone: _____________________
Weight: ________________________________
Work Phone: _____________________
Age: __________________________________
Mobile Phone: ____________________
Race: _________________________________
Email: ___________________________
Marital Status: __________________________
Preferred Contact: _________________
EMPLOYMENT
SOCIAL HISTORY
Employment Status: ________________
Alcohol Drinks/Week: __________________
Occupation: ______________________
Tobacco Use: _________________________
Company/School: __________________
I do not use any tobacco
Phone: __________________________
I did smoke but quit ________ years ago
Street: ___________________________
___________________________
City: ____________________________
State: ___________________________
I smoke _______ cigarettes per day
I smoke _______ cigars per day
I use chewing tobacco
Zip Code: ________________________
I currently use a nicotine patch or gum
HOW DID YOU HEAR ABOUT US?
I live with someone who smokes
Web Site
Newsletter
MEDICAL HISTORY
Seminar
# of Pregnancies: ________________________
Physician’s Name ______________
Implant Devices
(Defibrillator, Pacemaker): ________________
Patient’s Name ________________
History of Bruising Easily: ________________
Other _______________________
Are You Right or Left Handed: _____________
ALLERGIES
Allergies to Medication: __________________
Reaction: ____________________________
__________________
____________________________
__________________
____________________________
__________________
____________________________
Allergies: General (i.e.: Latex, Mold, Cats, Food, etc.)
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
CURRENT MEDICATIONS: PRESCRIPTIONS
Name:
Dosage:
Frequency:
CURRENT MEDICATIONS: OVER THE COUNTER AND/OR SUPPLEMENTS
Name:
Dosage:
Frequency:
______________________________________________________________________________
______
RELEVANT MEDICAL HISTORY
Never
Past
Currently
Frequency
Family History
NERVOUS SYSTEM:
________________________________________________
CARDIAC/HEART:
________________________________________________
HEMATOLOGICAL/BLOOD:
________________________________________________
PULMONARY/CHEST:
________________________________________________
RENAL/URINARY:
________________________________________________
DIGESTIVE:
________________________________________________
SKIN:
________________________________________________
BREAST:
________________________________________________
CANCER:
________________________________________________
PAST SURGICAL HISTORY
Operation
Date
Surgeon
Complications
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
MENTAL HEALTH HISTORY
PLEASE INITIAL YES OR NO:
YES
NO
Have you previously been involved in counseling?
_______
_______
Is there a history of mental health problems in your family?
_______
_______
Have you ever been physical abused?
_______
_______
Have you ever attempted suicide?
_______
_______
Have you been hospitalized for mental health reasons?
_______
_______
Is there a history of alcohol or drug problems in your family?
_______
_______
Have you ever been treated for depression?
_______
_______
Have you ever been treated for a panic disorder?
_______
_______
______________________________________________
PATIENT SIGNATURE
__________________
DATE
IF YOUR INSURANCE IS RELEVANT TO YOUR VISIT OR CARE
AT
BOSTON PLASTIC SURGERY ASSOCIATES,
PLEASE COMPLETE THE FOLLOWING:
INSURED PARTY
INSURANCE PROVIDER INFORMATION
Relationship: _____________________
Provider Name: _________________________
First Name: _______________________
Primary: _______________________________
Middle Name: ____________________
Street: _________________________________
Last Name: _______________________
_________________________________
Street: ___________________________
City: _________________________________
___________________________
State: _________________________________
City: ____________________________
Zip Code: ______________________________
State: ___________________________
Phone: ________________________________
Zip Code: ________________________
Contact: _______________________________
Employer: ________________________
Co-Pay: _______________________________
Phone: __________________________
Plan Name: _____________________________
Date of Birth: _____________________
Plan Type: _____________________________
Gender:
M ___
F ___
Insured’s ID #: ____________________
Policy #: _________________________
ADDITIONAL INSURANCE INFORMATION
Do you need a referral?
Yes________ No________
Do you need assistance in obtaining that information?
Yes________ No________
I understand I will be responsible for fees incurred if not covered because a referral
was not obtained.
___________________________________________
Signature
_____________________
Date
Do you have Medicare or Medicaid?
Yes________ No________
Do you have additional insurance?
Yes________ No________
If yes, what is it? _______________________________________________________
Primary Care Physician ___________________________________________________
BOSTON PLASTIC SURGERY ASSOCIATES PHOTOGRAPH CONSENT
I consent to the taking of photographs by Dr. Brooke R. Seckel and/or Dr. Sean T. Doherty or
their designee of me or parts of my body in connection with the plastic surgery procedure(s) to be
performed by Dr. Brooke R. Seckel and/or Dr. Sean T. Doherty. I further authorize Dr. Brooke R.
Seckel and/or Sean T. Doherty or one of their associates to release to the American Society of
Plastic Surgeons (ASPS) or any authorized parties such photographs.
I provide this authorization as a voluntary contribution in the interests of public education. I
understand that such photographs shall become the property of Dr. Brooke R. Seckel and/or Dr.
Sean T. Doherty and may be retained by Dr. Brooke R. Seckel and/or Sean T. Doherty or released
by Dr. Brooke R. Seckel and/or Sean T. Doherty for the limited purpose of including them in any
print, visual or electronic media, specifically including, but not limited to, medical journals and
textbooks, for the purpose of informing the medical profession or the general public about plastic
surgery procedures and methods.
Neither I, nor any member of my family, will be identified by name in any publication. I
understand that in some circumstances the photographs may portray features that will make my
identity recognizable.
I understand that I may refuse to authorize the release of any health information and that my
refusal to consent to the release of health information will prevent the disclosure of such
information, but will not affect the health care services I presently receive, or will receive, from
Dr. Brooke R. Seckel and/or Sean T. Doherty.
I understand that I have the right to inspect and copy the information that I have authorized to be
disclosed. I further understand that I have authorized to be disclosed. I further understand that I
have the right to revoke this authorization in writing at any times, but if I do so it won’t have any
effect on any actions taken prior to my revocation. If I do not revoke this authorization, it will
expire ten years from the date written below.
I understand that the information disclosed, or some portion thereof, may be protected by state
law and/or the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA).
I release and discharge Dr. Brooke R. Seckel and/or Sean T. Doherty, and all parties acting under
their license and authority from all rights that I may have in the photographs and from any claim
that I may have relating to such use in publication, including any claim for payment in connection
with distribution or publication of the photographs.
I certify that I have read the above Authorization and Release and fully understand its terms.
Signature ____________________________________Date________________________