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Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S Patient Intake Form First Name: ____________________ M.I. ____ Last Name _______________________ Date: ___ /___ /___ Date of Birth: ___ /___ /___ Marital Status: (Check One) Single Married Widowed Divorced Address: ______________________________________________________ City: __________________________ State: ______ Zip: _____________ Phone: _________________________ Work Phone: _________________________ Social Security: ____________________ Email: _________________________________ Employer: __________________________________________________ Emergency Contact: _________________________________________ Phone: _________________________ How did you select our office? (Check applicable boxes) www.loveyourlook.com www.docshop.com www.locateadoc.com www.breastimplants411.com www.aboardcertifiedplasticsurgeon.com www.drverne.com.com www.drverneweightloss.com Existing Patient Name: ______________________________________ (information is confidential) Family or Friend who is not a patient Physician ____________________________________ Television Other Financial Responsibility This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered, including reasonable attorney’s fees and costs of collection in the event of default. Date: ___ /___ /___ Signature: ________________________________________ 195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933 PSC-PIP-12-02-11 © Copyright 2011, Plastic Surgery Center 1 Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S Medical History and Physical Patient Name _____________________________________________________ Date: ___ /___ /___ Height: ____________ Weight: ____________ BMI: ____________ Surgery Date: ___ /___ /___ Age: _______ Date of Birth: ___ /___ /___ Occupation: _________________________________ Primary Care Doctor Name: ____________________________________ Number: ______________________ Specialty Care Doctor Name: ___________________________________ Number: ______________________ Date of Last Complete History and Physical: ___ /___ /___ Allergies (please list all allergies including latex, tape and food) Allergic to: _____________________________ Reaction: ____________________________________________ Allergic to: _____________________________ Reaction: ____________________________________________ Medications (please list all medications, prescriptions or over-the-counter or herbal remedy and dose, ex: 5 mg twice a day) Medication: ___________________ Dose: _________ Medication: ___________________ Dose: _________ Medication: ___________________ Dose: _________ Medication: ___________________ Dose: _________ Social and Personal Mental Health Regular Aspirin use: y n dosage & frequency ____________________________ NSAID (Advil, Motrin, Ibuprofen): y n dosage & frequency ____________________________ Cortisone Injection Past Year: y n dosage & frequency ____________________________ Have you ever used tobacco? y n if yes, average # of packs a day ______ Number of year’s smoked _____ Year’s quit ______ _ When was your last cigarette? ___________________ Do you drink alcohol? y n If yes, how many per week? ________ Ever used LSD/speed/cocaine/ marijuana? y n when: _______________________________ Recent weight change? y n If yes, increase (up) or decrease (down) How much? _________ Is stress a major problem for you? y n Do you feel depressed? yn Do you panic when stressed? yn Do you have any problems with eating/your appetite? yn Do you cry frequently? yn yn Have you ever attempted suicide? yn Do you have trouble sleeping? Have you ever been to a counselor? yn Have you ever taken psychiatric medication(s)? yn Do you currently take psychiatric medication(s)? yn Were you to have cosmetic surgery, please explain how you would anticipate that your life would be different following the procedure? _____________________________________________ _____________________________________________ _____________________________________________ 195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933 PSC-PIP-12-02-11 © Copyright 2011, Plastic Surgery Center 2 Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S Medical History Surgical History Have you ever had: High Blood Pressure High cholesterol Chest pain Heart disease Stroke Palpitations yn yn yn yn yn yn Other: ___________________________ Other: ___________________________ Do you currently have: Asthma Shortness of breath Snore loudly Obstructive sleep apnea Use Continuous Positive Airway Pressure Machine Diabetes If yes: medication insulin none Thyroid problems Reflux/ Heartburn Clotting problems Muscle or nerve disease Hepatitis Cancer HIV/ AIDS Woman Patients Only Age: ________ Date of last mammogram: ___ /___ /___ Last period: ___ /___ /___ yn yn yn yn yn yn yn yn yn yn yn yn yn yn What Surgeries have you had? When? _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Have you ever had anesthesia before? y n If yes, did you have any serious problems? Explain: ______________________________________ Do you have a family history of unexpected death following general anesthesia or exercise? y n Do you have a personal history of: Muscle spasm yn Dark or chocolate colored urine yn Unanticipated fever immediately following anesthesia or serious exercise? y n Do you or family have a history of: Malignant hyperthermia yn Muscle or neuromuscular disorder yn High temperature following exercise yn Clotting problems yn Have you had cosmetic surgery before? yn Indicate the type(s) of anesthesia received in the past, list any complications/ reactions you experienced: Local Anesthesia- complications/ reactions: _____________________________________________ General Anesthesia- complications/ reactions: _____________________________________________ Spinal/ epidural- complications/ reactions: _____________________________________________ Previous nausea & vomiting with surgery? y n Have you ever had motion sickness? yn 195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933 PSC-PIP-12-02-11 © Copyright 2011, Plastic Surgery Center 3 Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S Authorization for Examination and Treatment Last Name: ______________________________ First Name: ________________________ M.I. __________ Address: ________________________________________________________________ City: _______________________________ State: ________ Zip: ________________ Home Phone: ________________________ Cell Phone: ________________________ Other Phone: ________________________ I __________________________________ present to the physicians and staff that I am at least 18 (eighteen) years of age or, if not, am accompanied by a legal guardian. I hereby consent to and authorize examination and treatment by my doctor and such assistants or staff as assigned by him or her. Signature: _____________________________________ Date: ___ /___ /___ Relationship: (check one) PATIENT SPOUSE PARENT GUARDIAN Authorization of Medical Information I authorize release of medical information to the following persons: Name: _____________________________________________ Relationship: ____________________________ Name: _____________________________________________ Relationship: ____________________________ Name: _____________________________________________ Relationship: ____________________________ Signature: _____________________________________________ Date: ___ /___ /___ 195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933 PSC-PIP-12-02-11 © Copyright 2011, Plastic Surgery Center 4 Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S HIPAA Release Dear Patient: Under the Patient Privacy Act we are giving you this form to update our files as well as ascertain your approval to provide future information on our services and the practice’s activities. It is our goal to keep all our patients abreast of not only what is happening in our practice, but any innovations within cosmetic surgery that might benefit you or your family and friends. Please complete the information below and return it to us prior to your appointment, along with your other paperwork. Also, visit our Web site as www.drverne.com to review our full Patient Privacy Policy. We also have a copy in our office for your convenience. Verne Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S. Please Print Name: ___________________________________________________________ Address: _________________________________________________________ City: __________________________ State: _________ Zip: _______________ Home Phone: _______________________________ Work Phone: ________________________________ Cell Phone: _______________________________ E-Mail Address: ____________________________________ Please check your preferences for method(s) of contact below: Home Phone Work Phone Cell Phone E-Mail I am interested in remaining on the patient contact list of Plastic Surgery Center and receiving information on upcoming seminars, new services, newsletters and other information on cosmetic surgery that might benefit my family or me. Yes No Signature: _____________________________________________ Date: ___ /___ /___ 195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933 PSC-PIP-12-02-11 © Copyright 2011, Plastic Surgery Center 5 Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S Requirements For Surgery at Plastic Surgery Center Please understand the importance of obtaining this medical information to provide you with a safe experience. Please direct any medical questions to the CLINICAL STAFF (NOT the patient care coordinators). Your surgery may be postponed if the requested medical information is not received prior to your preoperative appointment (PAT). The following medical information must be received PRIOR to your (PAT) for your scheduled surgery. Please fax all requirements to: Plastic Surgery Center, FAX: # (207) 871-9316 1. Anesthesia may require you to have a complete history and physical exam including lab tests by your medical provider, even if you do not take any medications. 2. Any patient with a medical condition or on a medication prescribed by a physician must have a history and physical and lab work done within 1 year of their surgery date. 3. P atients over 50 years of age in good health, and on NO medications must have a History and Physical and routine Lab Work which includes: Complete metabolic profile (Chemistry), Complete Blood Count, Lipids (cholesterol, triglycerides, HDL, LDL) within 2 years. 4. If you are over 65, you must have all of the above PLUS an EKG If you have had these done, please fax copies to PSC. If your doctor has done an EKG, please include a copy. If you have NOT had a check-up or labs within the specified time frames, you must schedule an appointment with your doctor PRIOR to your PAT so we can review the requested information BEFORE your PAT. Breast Surgery Patients Any female 35 years or older, any female with breast disease, or a family history of breast cancer must have a mammogram For all appointments, such as consults, surgeries, and follow-ups, if you have any acute illness, such as strep throat, flu-like symptoms, fever, or cold, PLEASE call the office to reschedule 24 hours in advance. We are a health awareness facility. * As a courtesy to all our patients, it is very important that you arrive 15 minutes before your scheduled appointments. 195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933 PSC-PIP-12-02-11 © Copyright 2011, Plastic Surgery Center 6 Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S Directions From the South: Take 1-295 northbound to Exit #4. Cross the Veteran’s Bridge. At the traffic light you should be in the left hand lane and turn left onto the Fore River Parkway. Go through the next traffic light. The main entrance and patient drop-off are ahead on your right. Follow signs for patient parking. From the North: Take 1-295 southbound to Exit #5A. At the end of the ramp you should be in the left lane. Take a left at the traffic light and remain in the left hand lane, continue straight onto the Fore River Parkway. The main entrance and patient drop-off are ahead on your left. Follow signs for patient parking. From the Casco Bay Bridge: From South Portland go through the light at the State Street intersection and stay in the right lane, turning right onto Park Street. Take another right at the stop sign onto Commercial Street. Head west on Commercial Street to the Veteran’s Bridge intersection. Proceed straight through the light over the bridge onto the Fore River Parkway. Go through the next traffic light. The main entrance and patient drop-off are ahead on your right. Follow signs for patient parking. From the West(Congress St. and Rte. 22): Heading east on Congress St/Rte #22, take a right at the traffic light after Norway Savings Bank, following the signs for South/1-295/Rte. 1/South Portland. At the next traffic light you should be in the left hand lane and continue straight onto the Fore River Parkway. The main entrance and patient drop-off are ahead on your left. Follow signs for patient parking. 195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933 PSC-PIP-12-02-11 © Copyright 2011, Plastic Surgery Center 7