429 N. Ferncreek Avenue, Orlando, FL 32803

phone(407) 777-2071

 

New Patient Registration Fields marked with * are required

New Patient Questionnaire Fields marked with * are required

Responsible Party (if someone other than patient) Fields marked with * are required

Insurance Information Fields marked with * are required

Secondary Insurance Information Fields marked with * are required

Health History Fields marked with * are required

Are you allergic to any of the following? Fields marked with * are required

Do you have, or have you had, any of the following? Fields marked with * are required

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

Terms And Conditions Fields marked with * are required
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 Fields marked with * are required

HIPAA and Privacy Practices Consent Fields marked with * are required
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 Fields marked with * are required
Date: 12/2/2020