Patient Profile

I prefer the staff refer to me as _________________________________

Doctor:

PATIENT INFORMATION
Name:

_______________________________________

Sex:

_______________________________________
_______________________________________
City,State:_______________________________________

Date of Birth: _______________________________________

Social Security #: _______________________________________
Marital Status:
[ ]Married [ ]Single [ ]Divorced

Address:

Phone:
Phone:

(
(

)
)

[ ]M [ ]F

[ ]Home [ ]Work [ ]Other

[ ]Home [ ]Work [ ]Other

PATIENT EMPLOYMENT

Referring Physican:
Primary Physician:

_______________________________________
_______________________________________

CONTACTS

[ ]Employed [ ]Retired [ ]Other

A secure message may be left at _______________________________

_________________________________________________________

Phone:
(
)
Employer: _______________________________________

_________________________________________________________

GUARANTOR [ ]Same as Patient

EMPLOYMENT

Name: _______________________________________

Employer: ________________________________________________
Phone: __________________________________________________
Phone: __________________________________________________
Social Security #: __________________________________________
Date of Birth: _____________________________________________

Address: _______________________________________

_______________________________________
City,State: _______________________________________

PRIMARY INSURANCE
Insured Party:

_______________________________________
_______________________________________

Insured Phone:
Company:

_______________________________________

Policy Group:

Insured Party:

_______________________________________

_______________________________________

Policy Group:

Social Security #:

_______________________________________

_______________________________________

Date of Birth:

_______________________________________

[ ]Same as Patient [ ]Same as Guarantor [ ]Other

_______________________________________

Insured Phone:

Relationship to Patient: ______________________________________

Insured ID:

_______________________________________

SECONDARY INSURANCE

Company:

[ ]Same as Patient [ ]Same as Guarantor [ ]Other

Relationship to Patient:
Social Security #:
Insured ID:

_______________________________________

______________________________________

_______________________________________

_______________________________________

Date of Birth:

_______________________________________

Whom may we thank for referring you? ______________________________________________________________________

PATIENT AUTHORIZATION
I, __________________________________, hereby authorize The Center for Plastic Surgery, P.C. to apply for benefits on my
behalf for covered services rendered. I certify that the information I have reported with regard to my insurance coverage
is correct and further authorize the release of any necessary information, including medical information of this or any
related claim to the insurance company(s) listed above. I also agree that it is my responsibility to obtain a referral from
my primary care physician when applicable and am responsible for any and all Center for Plastic Surgery fees that exceed
or that are not covered by Insurance.
I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me at anytime
in writing. I authorize the taking of photography for medical purposes.

______________________________

_______________

Signature of Patient or Authorized Person

Date

WE WILL NEED TO COPY YOUR INSURANCE CARDS FOR YOUR CHART

THANK YOU
Center for Plastic Surgery, PC

CENTER FOR PLASTIC SURGERY

HEALTH QUESTIONNAIRE
PATIENT NAME: ______________________________________________ DATE: _________________
DATE OF BIRTH: ______________________ AGE: ______ SEX : M
Are you under the care of a physician?

HT: ______ WT: ______

If yes, please list name and address: ______________

______________________________________________________________________________________
When were you last seen by your regular physician? ___________________________________________
Have you ever had surgery?

If yes, please describe: ________________________________

______________________________________________________________________________________
Have you or any family members had any problems with anesthesia? Y

If yes, please explain?

______________________________________________________________________________________
Please list your previous hospitalizations:_____________________________________________________
Are you taking any medications?

If yes, please list __________________________________

______________________________________________________________________________________
(Please include over the counter medications such as aspirin or antihistamines)
Are you allergic to any medication? Y
Are you allergic to Latex?
Y
Do you smoke?
Y
Do you drink alcohol? Y
Are you pregnant?
Y

N
N
N

N
N

If yes, please list: _________________________________

If yes, how many packs per day? _____________

If yes, how much? _____________________
Are you Nursing
Y
N

Do you have a history of any of the following:

Asthma
Y
N
Thyroid Problems
Bronchitis
Y
N
Anemia
High Blood Pressure Y
N
Stroke
Liver Problems
Y
N
Glaucoma
Ulcers
Y
N
Hepatitis
Bleeding Problems
Y
N
Arthritis
Blood clots in the
Seizures
lungs or legs
Y
N
Diabetes
Cancer
Y
N
Depression
Sleep Apnea
Y
N
MRSA/Staph Infections
HIV
Y
N
Other Medical Problems

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N
N

If you answered YES to any of the above, please explain: ______________________________________

______________________________________________________________________________________
Do you now, or have you ever used recreational drugs? Y
Have you ever had a blood transfusion?

How would you describe your present health:

If so, when was the last time? ________

Is so, when: ______________________________

Excellent

Good

_____________________________________________________________
Patient/Guardian Signature

Fair
__________________
Date

PATIENT CONSENT FORM

Center for Plastic Surgery
1. I acknowledge that I have been given a copy of the Practices HIPAA Privacy Notice
which describes the Practices obligation to ensure the privacy of my health information. The
HIPAA Privacy Notice also describes how the Practice may use and disclose my health
information for treatment, payment and health care operations. I know that I have the right to
review the Practices HIPA Privacy Notice prior to signing this consent, and I have had the
opportunity to read the Practices HIPAA Privacy Notice and to ask questions about it. I
understand that the Practice is required to maintain the privacy of my health information in
accordance with the terms of its HIPAA Privacy Notice.
2. I further acknowledge that the Practice can change its HIPAA Privacy Notice in the future,
and that I can receive a copy of the Practices current Privacy Notice at anytime by contacting
Stanley R. Zausmer (301) 652-7700 or by checking the Practices website at
www.cpsdocs.com.
3. I understand that I have the right to request that the Practice restrict its uses and disclosures of
my health information for treatment, payment, or health care operations. If my restrictions
are accepted by the Practice, these restrictions will be binding on the Practice. I also
understand that the Practice is not required to agree to my requested restrictions.
I do not request any restrictions on the Practices use and disclosure of my health information
for treatment, payment or health care operations. ___________ (Initial)
4. By signing this form, I consent to the Practices use and disclosure of my health information
for treatment, payment and health care operations. I understand that I have the right to
revoke this consent at anytime in writing, but if I do, my revocation will not have an effect on
any actions the Practice has already taken in reliance on this consent.

_____________________________________
Signature of patient or patients representative

_______________________
Date

(This form must be completed before signing)

If this form is signed by a patients representative, please complete the following:
Print the name of patients representative:

_______________________________________

Describe the representatives authority to act for the patient:

*NOTE: YOU MAY REFUSE TO SIGN THIS CONSENT*

HOWEVER IF YOU DO REFUSE, THE PRACTICE MAY
REFUSE TO PROVIDE YOU WITH NON-EMERGENCY CARE.