PDF Legacy Plastic Surgery New Patient Intake Form

[Pages:4]Legacy Plastic Surgery New Patient Intake Form

Patient Information

First Name: __________________________ Last Name: _____________________________

MI: __________

Date: ______________________

Date of Birth: _____________ Age:_______________ Sex: M / F Race: ______________

Circle Ethnicity:

Hispanic/Latino

Non-Hispanic/Latino

Preferred Language: Spanish English Other

Marital Status:________________

Reason for visit: _____________________________________________________________

How did you hear about us? ___________________________________________________

Street Address: _______________________________________________________________

City, State, Zip: _______________________________________________________________

Home Phone: ____________________________ Cell Phone: _________________________

Email Address: ________________________________________________________

Circle preferred contact method:

Home Phone Cell Phone Work Phone

Work Status: Full Time

Part Time

Student

Occupation:_____________________________________

Employer/School: __________________________________

Work Phone: ________________________________________

Emergency Contact First Name: ________________________ Last Name:________________________________

Phone: _______________________________________

Relationship: ____________________________________

Primary Care Physician:

Name: ________________________________ Phone: ______________________________

Referring Physician:

Name: ________________________________ Phone: ______________________________

Legacy Plastic Surgery 460 Creamery Way, Suite 110

Exton, PA 19341

Patient Name: ______________________________ Date:____________________ Patient Medical History ? Check all that apply

List past surgeries / hospitalizations and dates ? if none write "none" ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Legacy Plastic Surgery 460 Creamery Way, Suite 110

Exton, PA 19341

Patient Name: ______________________________ Date:____________________

Family History Check all Family member with

(do not include self) that apply

condition

Abnormal Bleeding

Abnormal Clotting

Adopted

Anesthesia Problems

Autoimmune Disorder

Brain Tumor

Breast Cancer

Cleft Lip or Palate

Dementia

Depression

Diabetes

Drug Allergies

Endocrine Disease

Hearing Loss

Heart Disease

Hemophilia

High Blood Pressure

Kidney Disease

Liver Disease

Lung Cancer

Malignant Hyperthermia

Allergies: ___________________________________ ___________________________________ ___________________________________

Current Medications and Dosage:

___________________________________

___________________________________

___________________________________

Pharmacy Name: _____________________ Pharmacy Phone: ____________________

Social History: check the one that applies Alcohol:

No Alcohol use Alcohol use socially Alcohol use daily History of Alcoholism

Illegal Drugs:

No Illegal drug use Illegal drug use socially Illegal drug use daily History of illegal drug abuse

Smoking Status:

Current Everyday

Current Some Days

Former

Start:

Never smoked

End:

Skin Cancer Skin Disease Substance Abuse Von Willebrand Other Cancer

Height / Weight / BMI Height (inches): Weight (lbs): BMI:

Other Condition

No Pertinent Medical History

Legacy Plastic Surgery 460 Creamery Way, Suite 110

Exton, PA 19341

Today's Date: _____________ Patient's Name: _____________

D.O.B. _____________

Medical History Verification

All information provided is accurate and complete to the best of my knowledge. Patient Initials: __________ Parent or Guardian Initials: __________ Date: ___________

AUTHORIZATION OF RELEASE OF INFORMATION I hereby authorize the physician to release information requested by my insurance company or Workman's compensation carrier. I also authorize my physician to release information to any hospital or physician I may be referred to or referred from. Patient Initials: __________ Parent or Guardian Initials: __________ Date: ___________

ASSIGNMENT OF BENEFITS I hereby authorize assignment and payment directly to my physician major benefits due to me. Patient Initials: __________ Parent or Guardian Initials: __________ Date: ___________

PRIVACY NOTICE I acknowledge that I have received a copy of Legacy Plastic Surgery's privacy notice. Patient Initials: __________ Parent or Guardian Initials: __________ Date: ___________

Legacy Plastic Surgery 460 Creamery Way, Suite 110

Exton, PA 19341

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