Friedman Plastic Surgery New Patient Intake

Weclome to Friedman Plastic Surgery's Digital Intake Form

To get started, click the next button below. Please fill out all required fields, and as much available information as possible.

Once submitted, your information will be securely sent to the office staff. You may also print the completed forms if you'd like. There will be a print button after submission.

If you have any questions, don't hesitate to contact us at CareTeam@drfplasticsurgery.com

Today's Date*

MonthDayYear
Date
PATIENT INFORMATION
PATIENT'S NAME*

FIRST NAMEMiddle InitialLAST NAME
CELL PHONE NUMBER*
EMAIL ADDRESS*
example@example.com
I AGREE TO RECEIVING EMAILS FROM FRIEDMAN PLASTIC SURGERY*

YES I AGREE
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SEX ASSIGNED AT BIRTH*

MALEFEMALE
CURRENT GENDER IDENTITY*

MALEFEMALETRANSGENDER MALE / TRANSMAN / FTMTRANSGENDER FEMALE / TRANSWOMAN / MTFGENDER QUEERPREFER NOT TO SAY
DATE OF BIRTH*

MonthDayYear
Date
Age
SSN
EMPLOYER / SCHOOL*
OCCUPATION*
WHO REFERRED YOU TO OUR PRACTICE?
EMERGENCY CONTACT INFORMATION
IN CASE OF AN EMERGENCY, WHO SHOULD WE NOTIFY?
Name*

FIRST NAMELAST NAME
RELATION*
CELL PHONE NUMBER OF EMERGENCY CONTACT*
ASSIGNMENT AND RELEASE
I CERTIFY THAT I, AND/OR MY DEPENDENT(S), HAVE INSURANCE COVERAGE WITH (PLEASE TYPE THE NAME OF YOUR INSURANCE CARRIER BELOW)*
NAME OF YOUR INSURANCE CARRIER
AND ASSIGN DIRECTLY TO DR. DAVID J. FRIEDMAN ALL INSURANCE BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE. I AUTHORIZE THE USE OF MY SIGNATURE ON ALL INSURANCE SUBMISSIONS. THE ABOVE-NAMED DOCTOR MAY USE MY HEALTH CARE INFORMATION AND MAY DISCLOSE SUCH INFORMATION TO THE ABOVE-NAMED INSURANCE COMPANY (IES) AND THEIR AGENTS FOR THE PURPOSE OF OBTAINING PAYMENT FOR SERVICES DETERMINING INSURANCE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES. (SIGNATURE OF PATIENT, PARENT, GUARDIAN, OR OTHER REPRESENTATIVE BELOW)*

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NAME OF THE ABOVE SIGNER*

First NameLast Name
TODAY'S DATE*

MonthDayYear
Date
PATIENT HEALTH HISTORY
PATIENT'S NAME*

First NameMIDDLE INITIALLast Name
TODAY’S DATE*

MonthDayYear
Date
DATE OF BIRTH*

MonthDayYear
Date
HEIGHT*
WEIGHT*
IN LBS.
DATE OF LAST PHYSICAL EXAM (if unsure, check the box below)*

MonthDayYear
Don't know your last physical exam date?

I am not sure
REASON FOR APPOINTMENT*
PHARMACY NAME*
PHARMACY ADDRESS*
GENERAL SYMPTOMS

CHECK ALL THAT APPLY, OR LEAVE BLANK IF NONE APPLY
CURRENT SYSTEMIC SYMPTOMS

CHILLSCHEST PAINBLEEDING GUMSPERSISTENT COUGHDEPRESSIONHIGH BLOODBLURRED VISIONRINGING IN EARSDIZINESSCROSSED EYESSINUS PROBLEMSFAINTINGIRREGULAR HEART BEATDIFFICULTY SWALLOWINGVISION-FLASESFEVERVISION-HALOSFORGETFULNESSLOW BLOOD PRESSUREDOUBLE VISIONNOSEBLEEDSHEADACHEEARACHELOSS OF HEARINGLOSS OF SLEEPPOOR CIRCULATIONHAY FEVERNERVOUSNCESSRAPID HEART BEATHOARSNESSSWEATSSWELLING OF ANKLESVARICOSE VEINS
SKIN SPECIFIC SYMPTOMS

BRUISE EASILYHIVESITCHINGMOLE CHANGESSCARSRASHSORES THAT WON'T HEAL
FEMALE SPECIFIC
DATE OF LAST MENSTRUAL PERIOD*

MonthDayYear
DATE OF LAST PAP SMEAR*

MonthDayYear
DATE OF LAST MAMOGRAM*

MonthDayYear
ARE YOU PREGNANT*

YESNOCURRENTLY TRYING
PREGNANT OUTPUT*
NUMBER OF CHILDREN*
CONDITIONS

CHECK ALL THAT APPLY OR LEAVE BLANK IF NONE APPLY
CURRENT CONDITIONS

AIDSCHEMICAL DEPENDENCYHIGH CHOLESTEROLPROSTATE PROBLEMALCOHOLISMHIV POSITIVEPSYCHIATRIC CAREANEMIACHICKEN POXRHEUMATIC FEVERANOREXIADIABETESLIVER DISEASESCARLET FEVERAPENDICITISEMPHYSEMAMEASLESSTROKEARTHRITISEPILEPSYMIGRAINE HEADACHESSUICIDE ATTEMPTASTHMAGLAUCOMAMISCARRIAGETHYROID PROBLEMGOITERTONSILITISBREAST LUMPGONORRHEAMULTIPLE SCLEROSISTUBERCULOSISBRONCHITISGOUTMUMPSTYPHOID FEVERHEART DISEASECANCERVENEREAL DISEASEANOREXIABLEEDING DISORDERSBULIMIACATARACTSHEPATITISHERNIAHERPESKIDNEY DISEASEMONONUCLEOSISPACEMAKERPNEUMONIAPOLIOULCERSVAGINAL INFECTIONS
MEDICATIONS (LIST ALL MEDICATIONS YOU ARE CURRENT TAKING - ONE MEDICATION ON EACH LINE)
ALLERGIES (LIST ALL ALLERGIES TO MEDICATIONS / SUBSTANCES - ONE ALLERGY ON EACH LINE)
FAMILY HISTORY (FILL IN HEALTH INFORMATION ABOUT YOUR FAMILY)

FAMILY HISTORY

	AGE	STATE OF HEALTH	AGE OF DEATH	CAUSE OF DEATH
FATHER
MOTHER
BROTHER(S)


SISTER(S)

HAVE ANY OF YOUR RELATIVES HAD ANY OF THE FOLLOWING? CHECK ALL THAT APPLY OR LEAVE BLANK IF NONE.

ARTHRITIS, GOUTASTHMA, HAY FEVERCANCERCHEMICAL DEPENDENCYDIABETESHEART DISEASE / STROKEHIGH BLOOD PRESSUREKIDNEY DISEASETUBERCULOSISOther
WHO HAS HAD ARTHRITIS, GOUT?
RELATION TO YOU (E.G. UNCLE)
WHO HAS HAD ASTHMA, HAY FEVER?
RELATION TO YOU (E.G. UNCLE)
WHO HAS HAD CANCER?
RELATION TO YOU (E.G. UNCLE)
WHO HAS HAD CHEM. DEPENDENCY?
RELATION TO YOU (E.G. UNCLE)
WHO HAS HAD DIABETES?
RELATION TO YOU (E.G. UNCLE)
WHO HAS HAD HEART DIS. / STROKES?
RELATION TO YOU (E.G. UNCLE)
WHO HAS HAD HIGH BLOOD PRESSURE?
RELATION TO YOU (E.G. UNCLE)
WHO HAD HAD KIDNEY DISEASE?
RELATION TO YOU (E.G. UNCLE)
WHO HAS HAD TUBERCULOSIS?
RELATION TO YOU (E.G. UNCLE)
WHO HAD HAD THE OTHER DISEASE YOU LISTED ABOVE?
RELATION TO YOU (E.G. UNCLE)

PAST SURGERIES, ILLNESSES, OR HOSPITALIZATIONS

	DATE	HOSPITAL	REASON
1
2
3
4
5

HEALTH HABITS
DO YOU USE ANY OF THE FOLLOWING? (IF NONE, LEAVE BLANK)

CAFFEINETOBACCODRUGSALCOHOLOther
DESCRIBE CAFFEINE USE
DESCRIBE TOBACCO USE
DESCRIBE DRUG USE
DESCRIBE ALCOHOL USE
DESCRIBE USE OF OTHER LISTED ABOVE

HAVE YOU EVER HAD A BLOOD TRANSFUSION*

YESNO
APPROXIMATE DATE OF BLOOD TRANSFUSION

MonthDayYear
Date
OCCUPATIONAL CONCERNS
WHAT IS YOUR OCCUPATION?*
DOES YOUR OCCUPATION COME WITH ANY...

STRESSHAZARDOUS SUBSTANVESHEAVY LIFTINGOther
I CERTIFY THAT THE ABOVE INFORMATION ON THE PRECEEDING FORM IS CORRECT TO THE BEST OF MY KNOWLEDGE. I WILL NOT HOLD MY DOCTOR OR ANY MEMBERS OF HIS/HER STAFF RESPONSIBLE FOR ANY ERRORS OR OMISSIONS THAT I MAY HAVE MADE IN COMPLETION OF THIS FORM.*

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Date

MonthDayYear
Date
PATIENT HIPAA AWARENESS
WITH MY PERMISSION, DAVID J. FRIEDMAN, MD MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) ABOUT ME TO CARRY OUT TREATMENT, PAYMENT AND HEALTH OPERATIONS (TPO PLEASE REFER TO DR. FRIEDMAN'S NOTICE OF PRIVACY PRACTICES FOR A MORE COMPLETE DESCRIPTION OF SUCH USES AND DISCLOSURES.

I HAVE THE RIGHT TO REVIEW THE NOTICE OF PRIVACY PRACTICES PRIOR TO SIGNING THIS CONSENT. DR. FRIEDMAN RESERVES THE RIGHT TO REVISE THE NOTICE OF PRIVACY PRACTICES AT ANY TIME. A REVISED NOTICE OF PRIVACY PRACTICES MAY BE OBTAINED BY FORWARDING A WRITTEN REQUEST TO THE PRIVACY OFFICER. WITH MY PERMISSION, DR. FRIEDMAN HIMSELF OR HIS STAFF MAY CALL MY HOME OR OTHER DESIGNATED LOCATIONS AND LEAVE A MESSAGE ON VOICEMAIL OR IN PERSON REFERENCES TO ANY ITEMS THAT ASSIST THEM IN CARRYING OUT THE TPO, SUCH AS AN APPOINTMENT REMINDER, INSURANCE ITEMS, AND ANY CALL PERTAINING TO MY CLINICAL CARE, INCLUDING LABORATORY RESULTS; AMONGST OTHER MATTERS.

WITH MY PERMISSION, DR. FRIEDMAN, OR HIS STAFF MAY MAIL TO MY HOME OR OTHER DESIGNATED LOCATIONS ANY ITEMS THAT ASSIST THE PRACTICE IN CARRYING OUT TPO, SUCH AS, APPOINTMENT REMINDER CARDS, STATEMENTS, PRE-SURGICAL/POST-SURGICAL INFORMATION. I HAVE THE RIGHT TO REQUEST THAT DR. FRIEDMAN, OR HIS STAFF RESTRICT HOW THEY DISCLOSE MY PHI TO CARRY OUT TPO. HOWEVER, DR. FRIEDMAN, OR HIS STAFF IS NOT REQUIRED TO AGREE TO MY REQUESTED RESTRICTIONS; YET IF THEY ADHERE TO THE REQUEST THEN, IT WILL BE BOUND BY THIS AGREEMENT.

BY SIGNING THIS AGREEMENT, I AM ALLOWING DAVID J. FRIEDMAN, MD AND/ OR HIS STAFF TO USE AND DISCLOSE MY PHI FOR TPO.

I MAY REVOKE MY CONSENT IN WRITING EXCEPT TO THE EXTENT THAT THE PRACTICE HAS ALREADY MADE DISCLOSURES IN RELIANCE UPON MY PRIOR CONSENT.
SIGNATURE OF PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE*

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NAME OF PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE*

First NameLast Name
Date

MonthDayYear
Date
NOTICE OF INSURANCE DISCLOSURE
IF YOUR INSURANCE COVERAGE ALLOWS YOU TO GO OUT-OF-NETWORK, MEANING IF YOU HAVE OUT OF NETWORK BENEFITS; OUR OFFICE WILL ACCEPT YOUR INSURANCE AS PAYMENT IN FULL AS LONG AS YOUR ANNUAL DEDUCTIBLE AND CO-INSURANCE HAVE BEEN MET.

IF YOUR ANNUAL DEDUCTIBLE AND CO-INSURANCE HAVE NOT BEEN MET, THEN YOU ACKNOWLEDGE THAT YOU WILL BE RESPONSIBLE FOR THE PAYMENT OF YOUR DEDUCTIBLE AND/ OR CO-INSURANCE.

IF YOU SHOULD RECEIVE PAYMENT FROM YOUR INSURANCE CARRIER FOR SERVICES RENDERED BY DAVID J. FRIEDMAN, MD, YOU ACKNOWLEDGE THAT YOU WILL BE RESPONSIBLE FOR FORWARDING BOTH THE PAYMENT AND THE EXPLANATION OF BENEFITS (EOB) FORM, THAT YOUR INSURANCE COMPANY HAS SENT YOU. YOU MUST SEND BOTH THE PAYMENT AND EOB DIRECTLY TO OUR OFFICE IMMEDIATELY. IF YOU DO NOT SEND THE PAYMENT AND EOB TO OUR OFFICE YOU WILL RECEIVE A BILL, SO TO ENSURE THAT YOU DO NOT RECEIVE A BILL, PLEASE SEND ALL PAYMENTS AND EOB'S AS SOON AS POSSIBLE.

YOU WILL ASSUME RESPONSIBILITY FOR ANY COSTS ASSOCIATED WITH ANY COLLECTION AND/OR LEGAL PROCEEDINGS THAT MAY BE NECESSARY, IF YOU FAIL TO FORWARD PAYMENTS THAT YOU RECEIVE DIRECTLY TO OUR PRACTICE. IF YOU RECEIVE PAYMENT AND DO NOT REIMBURSE THE DOCTOR WITHIN THIRTY DAYS YOU WILL BE RESPONSIBLE FOR ENTIRE AMOUNT OF THE PROCEDURE.

IF YOUR INSURANCE CARRIER REFUSES TO PAY FOR SERVICES RENDERED BY DAVID J. FRIEDMAN MD, PLEASE BE ADVISED THAT YOU WILL RESPONSIBLE FOR ANY/ ALL USUAL CUSTOMARY FEES THAT TYPICALLY APPLY TO YOUR PROCEDURE.
SIGNATURE OF PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE*

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DATE

MonthDayYear
Date
NAME OF PATIENT, PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE*

First NameLast Name
Please upload photos of the front and back of your insurance card.

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Should be Empty:

	YEAR	SEX OF BIRTH	COMPLICATIONS IF ANY

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION

ASSIGNMENT AND RELEASE

PATIENT HEALTH HISTORY

GENERAL SYMPTOMS

FEMALE SPECIFIC

CONDITIONS

FAMILY HISTORY (FILL IN HEALTH INFORMATION ABOUT YOUR FAMILY)

HEALTH HABITS

OCCUPATIONAL CONCERNS

PATIENT HIPAA AWARENESS

NOTICE OF INSURANCE DISCLOSURE