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Download Zannis Center New Patient Packet updated 7-22-14
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Zannis Center for Plastic Surgery Patient Registration Form PATIENT INFORMATION Last Name: _______________________________ First: __________________ Address: _________________________________________________________________________________ Marital Status:____ City: _____________________ Date of Birth: ________/________/________ Home Phone: (______)__________________ Employer: _______________________________ State: ____________________ Male Middle: _________________ ZIP: ______________________ Female Age:____ SSN: _____________________ Cell: (______)______________ Work: (______)_____________ Email Address: ___________________________________ WELCOME TO OUR PLASTIC SURGERY CENTER WE ARE SO PLEASED THAT YOU HAVE CHOSEN OUR FACILITY FOR ALL YOUR PLASTIC SURGERY NEEDS Referred By: Yellow Pages ___________________ Friend/Name ________________ Friend’s Address: __________________________________ City/Zip Code __________________________________ ER Facility: __________________________ Referral Letter: Will send a thank you letter for referral Advertisement ______________ __________________ Website_______________ Yes__________ No__________ INSURANCE INFORMATION PRIMARY INSURANCE GUARANTOR INFORMATION Insurance Name _______________________________ Guarantor Name ______________________________ Group/Plan #: _______________________________ Guarantor SS# ______________________________ Policy/Member #: _______________________________ Guarantor DOB: ______________________________ Subscriber Name: _______________________________ Guarantor Employ ______________________________ Relationship/Sex: ________________________ Relationship/sex _______________________ Family Physician ______________________________ Guarantor Ins. _______________________________ Referral Required: Yes M F No Referral Required Guarantor Address Yes M F No Insured SS#: _______________________________ Insured DOB: _______________________________ _______________________________ Employer: _______________________________ _______________________________ Occupation: _____________________________ Guarantor Phone _______________________________ _______________________________ EMERGENCY CONTACT Please provide a contact that is not living with you. Name: _______________________________ Relationship: _______________________________ Phone Number: (________)_____________________ AUTHORIZATION FOR TREATMENT, BILLING AGREEMENT, AND RELEASE OF INFORMATION The above information is true to the best of my knowledge. I authorize John Zannis, M.D. and staff to provide treatment for myself or the above individual. I understand that I am ultimately responsible for charges associated with medical services and agree to pay all bills within 30 days of receipt of a statement, unless other arrangements are made. I authorize the physician and staff to release any information required to process my insurance claims. I understand that my medical record may contain sensitive information. I also authorize my insurance to directly pay Dr. Zannis/ The Zannis Center for Plastic Surgery. Patient/Responsible Party Signature _______________________________________________ Date _______________ Zannis Center for Plastic Surgery Patient History Form This information becomes part of your confidential medical record. Name ___________________________________________ Why are you consulting a plastic surgeon? ______________ What do you like to be called? ________________________ _________________________________________________ Age ___________________ _________________________________________________ Male Female MEDICAL ILLNESSES Please check if you have ever had: Heart disease High cholesterol High blood pressure Lung disease (COPD) Diabetes Bleeding problems Cancer Stroke Kidney disease Heartburn (Reflux) Drug addiction Depression/Anxiety Hepatitis (A, B, or C) HIV (AIDS) STD (syphilis, chlamydia) TB Please give details about your illnesses and describe any not listed above. ________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ SURGICAL HISTORY Please check if you have ever had: Tonsillectomy Appendectomy Gall bladder removal Hernia repair Prostate surgery Tubal ligation Hysterectomy Caesarian section Mastectomy Breast augmentation Abdominoplasty Facelift/Brow lift Please give details about your surgeries (year, surgeon) and describe any not listed above. ___________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Have you ever had problems with anesthesia? Y N If yes, what happened? _________________________________ ____________________________________________________________________________________________________ MEDICATIONS PRESCRIPTION DRUGS Name Dosage OVER THE COUNTER DRUGS, HERBS, AND VITAMINS Frequency Name Dosage Frequency _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ ALLERGIES DRUG ALLERGIES Name LATEX OR OTHER ALLERGIES Reaction Name Reaction _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ SOCIAL HISTORY Marital/Partner Status ______________________________ No. of Children __________ Ages __________________ Primary Care Physician _____________________________ Address _________________________________________ Your Occupation __________________________________ _________________________________________ Right or Left Handed? TOBACCO USE Phone _________________ None Packs/Cans per day ______________ No. of years used ______________ Year stopped ______________ Cigarettes Chew ALCOHOL USE None ____ drinks per day or ____ per week Alcohol problem? Yes No Date last seen ___________ DRUG USE None Marijuana Crystal Meth Other: _______________________ Prescription drug problem? Yes No FAMILY HISTORY Please check if any blood relative has had: Heart problems Stroke High blood pressure Cancer Melanoma Arthritis Diabetes Mental Illness Anesthetic problems Abnormal bleeding Abnormal clotting Tuberculosis Please give details (which family member, how serious) or describe any not listed above: ____________________________ ___________________________________________________________________________________________________ REVIEW OF SYSTEMS Please check if any of the following conditions apply to you: Fever Chills Chronic Fatigue Weight changes None EYES Eye pain Excessive tearing Dry eyes Contact lenses None EARS Ear pain Ringing in ears Hearing loss Dizziness None NOSE Past nasal trauma Past nasal surgery Deviated septum Sinus problems None Dental problems Oral cancer Dentures Jaw clicking None Chest pain Heart attack Heart Murmur Irregular heartbeat None Recent cough Shortness of breath Asthma Bronchitis None Nausea/Vomiting Constipation Diarrhea Ulcers None CONSTITUTIONAL MOUTH CARDIOVASCULAR RESPIRATORY GASTROINTESTINAL Recent UTI Difficulty urinating Yeast infections Kidney problems None MUSCULOSKELETAL Arthritis Fractures Low back pain Difficulty walking None NEUROLOGIC Stroke Seizures Sensory loss Muscle weakness None PSYCHIATRIC Depression Anxiety Psychosis Marital problems None Bleeding disorder Easy bruising Abnormal clotting Anemia None Diabetes Hypoglycemia Thyroid problems Adrenal problems None GENITOURINARY HEMATOLOGIC ENDOCRINE Please describe the answers you checked: ________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ CERTIFICATION By signing below, I certify that to the best of my knowledge all the information I have furnished on this form is complete, true, and accurate. Patient/Legal Guardian signature _____________________________________________________ Date ______________ FOR OFFICE USE Physician signature _______________________________________________________________ Date ______________ QUESTIONNAIRE Are you being seen today as a result of an accident? □ yes □ no If yes, date: ______________ Please explain: ______________________________________________________________________ If you were injured on the job, what is the name of the Workers’ Comp Insurance? _____________ Contact Person: ______________________________ Phone #:___________________________ Please check the areas you would like to discuss today: ______ Nose ______ Face Lift ______ Eyelids ______ Ears ______ Chin ______ Moles/Cysts ______ Liposuction ______ Scar Revision ______ Brow/Forehead Lift ______ Chemical Peel/Laser ______ Dermabrasion ______ Abdominoplasty ______ Breast Augmentation ______ Breast Reduction ______ Laser Hair Removal ______ Laser Skin Rejuvenation ______ Laser Wrinkle Reduction ______ Skin Care ______ Microdermabrasion When did you begin to consider surgical corrections? ________________ Have you consulted another physician about this? □ yes □ no Have you discussed this surgery with your family? □ yes □ no Are they agreeable? □ yes □ no Have you had cosmetic or reconstructive surgery? □ yes □ no Were there complications? □ yes □ no Did you have a normal recovery? □ yes □ no Were you satisfied with the results? □ yes □ no AUTHORIZATION FOR USE OF PATIENT PHOTOGRAPHS Name Address ______ ______ (street address, city, state and zip code) 1. CONSENT TO TAKE PHOTOGRAPHS I hereby authorize John Zannis, M.D. and or his associates or designees to take pre-operative, intraoperative, and post-operative photographs, slides, and/or video recordings. I additionally consent to photographs, slides, and/or videotapes of my interview. 2. CONSENT FOR RELEASE OF PHOTOGRAPHS I hereby authorize John Zannis, M.D. and or his associates or designees to use pre-operative, intraoperative, and post-operative photographs or video recordings for professional medical purposes deemed appropriate including, but not limited to, showing these images on public or commercial television, internet sites, for purposes of medical education, patient education, lay publication, or during lectures to medical or lay groups. I authorize the use of such photographs for documentation purposes as part of my medical record as well as use in advertisements, and marketing campaigns for the practice of Dr. Zannis. This includes print media as well as digital media such as internet sites. I release and discharge John Zannis, M.D. 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 of Patient / Parent or Legal Guardian Date The Zannis Center For Plastic Surgery, P.A. New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations I, _________________________, understand that as part of my healthcare, The Zannis Center For Plastic Surgery originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care and treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care A source of information for applying my diagnosis and surgical information to my bill A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: The right to review of the notice prior to signing this consent The right to object to the use of my health information for directory purposes The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations I understand that The Zannis Center For Plastic Surgery is required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that The Zannis Center For Plastic Surgery reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should The Zannis Center For Plastic Surgery change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, email). I wish to have the following restrictions to the use or disclosure of my health information: I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I fully understand and accept the terms of this consent. _________________________________ Patient Signature __________________ Date YOUR SIGNATURE IS NECESSARY FOR US TO PROCESS ANY INSURANCE CLAIMS AND TO ENSURE PAYMENT OF SERVICES RENDERED TO OUR PRACTICE AS WELL AS FOR COORDINATION OF CARE WITH YOUR OTHER DOCTORS. PLEASE PUT AN X IN THE SPACE PROVIDED THAT BEST DESCRIBES YOUR STATUS IN REGARDS TO YOUR INSURANCE COVERAGE. ______The Non-Medicare Patient I hereby assign to The Zannis Center For Plastic Surgery any and all benefits from my insurance plan/plans and authorize and direct such benefits to be paid directly to The Zannis Center For Plastic Surgery. I certify that the information given by me in applying for payment under my insurance plan is correct and complete. I authorize release of all records required to act on this release and assignment. ______The Medicare Patient I request that payment of authorized Medicare benefits be made on my behalf to The Zannis Center For Plastic Surgery for any services rendered. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable for related services. I certify that the information given by me in applying for payment under the Medicare program is correct and complete. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I authorize The Zannis Center for Plastic Surgery to release all medical information (including, but not limited to, information on psychiatric conditions, sickle cell anemia, alcohol and drug abuse, and HIV or communicable diseases) requested by my health insurance carrier, my referring physician and my primary (family) physician. I agree that these provisions will remain in effect until I provide written revocation to The Zannis Center for Plastic Surgery. I have read the information above and all my questions have been answered by the staff at The Zannis Center For Plastic Surgery. Patient: ________________________________________________ Signature: ________________________________________________ Witness: ________________________________________________ Date: ________________________________________________ Zannis Center For Plastic Surgery Patient Financial Policy We consider it a privilege that you have chosen us for your needs. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Cosmetic Surgery Initial Consultation - $50.00. This fee is due at the time an appointment is made. Consultation fee will be applied towards any surgery that is performed within one year of consultation. Cancellations that do not occur before 24 hours of the appointment forfeit this fee (No-show Fee). Consultation fee is waived for established patients (seen within the last 2 years). Surgery Deposit - $200.00. Deposit is due at the time surgery is scheduled to reserve date. It is applied towards surgery fee. If surgery is cancelled by patient less than 2 weeks in advance, deposit is forfeited. If surgery is cancelled day of surgery, patient will be charged $750.00 to cover staff time and OR supplies already utilized. Total Balance. Payment for the balance of the surgery fee is due at the preoperative History & Physical exam or 2 weeks prior to the operation, whichever comes first. If fees are not provided 5 business days before the scheduled procedure the surgery will be cancelled. If additional fees are incurred for preoperative testing, pathology or hospitalization, the patient is responsible for these in addition to the original quote. Revisions. Plastic surgery is an art and occasionally revisions will be necessary. The majority of the time no surgeon fees will be charged, however facility and anesthesia fees will apply for the procedure. Minimum revision charge: $250 (local anesthesia) or $600 (IV sedation). Multiple Procedure Discount - $350.00. Multiple procedures not already bundled will receive a $350.00 discount. Reconstructive Surgery Procedures Reconstructive consultation fees will be billed to your insurance company. We participate with most major insurance networks. We will ask for your insurance card at your first visit and subsequent visits to obtain a copy for our records. Insurance Submissions. As a courtesy, we will file your claims for you with your primary and secondary insurance carriers. Ultimately you are responsible for payment in full to The Zannis Center For Plastic Surgery. Our office is pleased to obtain pre-authorizations from your insurance carrier. This process may take 4 to 6 weeks. Surgery will not be scheduled until the authorization is received. Co-payments and Deductibles. These are due at the time you see the doctor and will be collected at check out. When your insurance company has paid their portion of the charge, a statement will be generated and mailed to you. Any balance due is your responsibility and is due upon receipt of the statement from our office. Work-related Injuries. Patients being seen as a result of work-related injuries are still responsible for charges incurred at the time of service. We will make every effort to collect your charges from your employer or their worker's comp insurance carrier. Disability Paperwork. There is $25.00 fee for completion of disability, leave of absence, and related forms. Collections. Unfortunately, should our billing office fail to collect the balance on a patient’s account, we must then place the account with our attorney collections. Should that occur, an administrative fee will be added to your account balance. Payment Methods. We accept payments by cash, check, VISA, or MasterCard. Cosmetic Surgery financing is also available through CareCredit®. Returned checks will incur an additional $35.00 overdraft charge. Medical Records. Copies of medical records will be provided within 30 days of written request. A retrieval fee of $10.00 for the first 15 pages plus $0.50 per page for each additional page must be received prior to releasing the records. I have read and understand the payment policy and agree to abide by its guidelines. _____________________________________ Signature of Patient or responsible party _______________ Date TYLENOL AND/OR EXTRA-STRENGTH TYLENOL IS OKAY TO TAKE. THE FOLLOWING MEDICATIONS THIN THE BLOOD AND RAISE THE RISKS OF EXCESSIVE BLEEDING DURING AND AFTER THE OPERATION: ALEVE ASPIRIN ADVIL ALKA SELTZER ANACIN APC APECTOL ARTHRITIS STRENGTH BUFFERIN ASA COMPOUND ASCRIPTIN ASPERGUM BUFF-A-COMP BC BUFFERIN BUTAZOLIDIN BUTABITAL W/APC CAPRON CAPSULES CETASID CONTAC CONGESPIRIN COPE CORICIDIN CORCIDIN CORCIDIN D COUMADIN COUNTERPAIN DARVON DEFORTE-DEFULE DOLOBID DRISTAN ECOTRIN EMPIRIN EQUAGESIC EXCEDERIN EXTRA STRENGTH BUFFERIN 4-WAY COLD TABLETS FIORINAL FISH OIL GEMNISYN GOODY’S POWDER IBUPROFEN INDOCIN LIQUIDSRIN TABLETS MIDOL MOTRIN NAPROSYN NORGESIC NOVAHISTINE W/APC PERCODAN PHENAPHEN PHENSOL PLAVIX ROBAXISAL SK-65 COMPOUND STANBACK SUPAC SUPER ANAHIST SYNALGOS TORADOL TRIGISIC TRIAMINIC VANQUISH VITAMIN E ZACTRIN ZORPHRIN DO NOT TAKE any of these medications or any medications containing aspirin or blood thinning agents for at least ten (10) days prior to surgery. PLEASE DO NOT TAKE DIET PILLS OR HERBAL MEDICINES FOR 30 DAYS PRIOR TO SURGERY. Please note: This list does not include all medications containing Aspirin! If you are currently taking any medications not listed above, consult with your physician prior to scheduling surgery. I have been instructed not to smoke _____days prior to my surgery. I understand that I may be tested the morning of surgery, and if the test results are positive for nicotine my surgery will be cancelled. ______ Initials 2021 Neuse Boulevard ∙ New Bern, NC ∙ (252) 633-1197
