429 N. Ferncreek Avenue, Orlando, FL 32803

(407) 777-2071

 

New Patient Registration

New Patient Questionnaire

Responsible Party (if someone other than patient)

Insurance Information

Secondary Insurance Information

Health History

Are you allergic to any of the following?

Do you have, or have you had, any of the following?

Did you know that we offer cosmetic and therpuetic Botox and Dermal Filler? If you are interested, please check the boxes below.

Terms And Conditions
I understand that the information that I have given today is correct to the best of my knowledge and that providing incorrect information can be dangerous to my (or patient's) health. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.                    

Release Authorization

HIPAA and Privacy Practices Consent
I give this practice/ clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
I give this practice consent to leave messages with household members and answering machines when necessary.
I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).
I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.                    

Signature
Date: 9/20/2020