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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________________________