Medical Patient Paperwork

Medical Patient Paperwork
Patient Name (as it appears on your drivers license) *

First Name Middle Name Last Name
Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Sex *

Female Male Other
Date of Birth *

Month Day Year
Social Security Number *
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Employment Information
Occupation *
Employer's Name
Employer's Phone Number
Please enter a valid phone number.
Address

Street Address

City State / Province

Postal / Zip Code
Emergency Contact Information
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Relationship *
Please Upload a photo of your drivers license

Cancel of
Please list what procedure(s) you are interested in *
How did you hear about us? *
Who was your referral? *
Name of Referral
Date of Appointment (if applicable)

Month Day Year
Date

Privacy Practices
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I, First Name Last Name, understand that, under the Health Insurance Portability & Accountability Act of 1966 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: 1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. 2. Obtain payment from third-party payers. 3. Conduct normal healthcare operations such as quality assessments and physician Certifications. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the above address to obtain a current comp of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
Name *

First Name Last Name
*

Clear
Confidential Communications
I request that all communication to me (by telephone, mail, or otherwise) by St. Louis Cosmetic Surgery, Inc., and/or its staff be handled in the following manner. For written communications, send to:
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
If you are unavailable at this number, may we leave a message on an answering machine or voicemail message? *

Yes No
Do we have permission to disclose your health information to another person other than yourself? *

Yes No
If yes, please list name and relationship below
*

Clear
Date *

Month Day Year
Date

COVID-19 Consent Form
I, the undersigned patient, consent to an in-person consultation and/or to have my Doctor and/or his/her staff (hereinafter collectively “my Doctor”) perform medical procedures, whether regarded as necessary, elective or aesthetic, during the time of the COVID-19 pandemic and after. I understand in-person consultations and/or having my procedure performed at this time, despite my own efforts and those of my Doctor, may increase the risk of my exposure to COVID-19. I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to my health, and even death. I am also aware of the possibility that the procedure itself, whether performed in my Doctor’s office or in a hospital, may result in a more severe case of COVID-19 than I might have had without the procedure. *
*
I also understand in-person consultations and/or having my procedure performed at this time increases the risk of my transmission of COVID-19 to my Doctor. This virus has a long incubation period, there may be as yet unknown aspects of its transmission, and I realize that I may be contagious, whether or not I have been tested or have symptoms. To reduce the possibility of COVID-19 exposure or transmission at my Doctor’s office, I accept that my Doctor will implement infection-control procedures with which I must comply, before, during and after my consultation and/or procedure, for my own protection as well as that of my Doctor. I understand my cooperation is mandatory, whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.
*
I have informed my Doctor of any COVID-19 testing I or any person living with me during the past 14 days has received, as well as the results of that testing, and if I am tested between now and the date of my procedure, I will immediately provide the results of that testing to my Doctor. I understand my Doctor may require that I be tested, possibly at my own expense and regardless of any prior testing, and that the results of that testing must be satisfactory to my Doctor, before I may receive my procedure. I understand I must honestly disclose this information to avoid putting myself and others at risk
*
All topics above have been discussed with me, and all my questions have been answered to my satisfaction. Being fully informed, I accept the risk of COVID-19 exposure and I will bear the cost of any COVID-19 treatments required. I have been given the opportunity to postpone my in-person consultation and/or procedure until the COVID-19 pandemic is less prevalent, but I choose to have my in-person consultation and/or procedure performed now. If I am the parent, guardian or conservator of the patient, I hold his/her health care power of attorney. I have read this COVID-19 Informed Consent Agreement and am authorized to consent on the patient's behalf.
*
Name *

First Name Last Name
Date *

Month Day Year
Date
*

Clear

COVID-19 Vaccination Status
Name *

First Name Last Name
Have you been vaccinated for Covid-19? *

Yes No
Have you been boosted for Covid-19?

Yes No
Please upload a photo of your vaccination card

Cancel of

Payment Policy
We strive to provide all of our patients with prompt and excellent medical care and to assist you in the handling of your bill. In order to maintain your account in good standing, our requirements for payment of your account are as follows:
- PAYMENT IS EXPECTED FOR ALL OFFICE VISITS, SERVICES, TREATMENTS, AND PRODUCTS AT THE TIME OF EACH VISIT.
- ALL CHARGES ARE DUE AND PAYABLE THE DATE THEY ARE INCURRED
- We do not accept the theory that legal cases should be settled before payment of the fee is due. ALL CHARGES ARE DUE AND PAYABLE THE DATE THEY ARE INCURRED.
Because our services are rendered to YOU, you are responsible directly to us for the settlement of your account within the time limit set. Please feel free to discuss your bill or charges at an early date, to avoid misunderstandings.

It is understood that failure to comply with this agreement would leave St. Louis Cosmetic Surgery, Inc. no alternative but to seek collection action.

The quote that you receive at your consultation will include the doctor’s fee, plus OR and anesthesia. Payment of these fees will be due prior to surgery.

We do not accept or file insurance claims. Our services are not covered by insurance.
Name *

First Name Last Name
*

Clear
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Medical Patient Paperwork

Employment Information

Emergency Contact Information

Medical Information

Privacy Practices

Confidential Communications

COVID-19 Consent Form

COVID-19 Vaccination Status

Payment Policy