New Patient Packet

PATIENT INFORMATION:




Address












RESPONSIBLE PARTY INFORMATION



Address











INSURANCE INFORMATION:











OTHER INFORMATION:


Is it okay with you to send a thank you note to the person who referred you to us?:




HEALTH HISTORY:

HAVE YOU HAD OR DO YOU STILL HAVE :
  1. Cold or cough within the last two weeks
  2. Breathing problems (asthma, etc)
  3. Chest pains or angina, or heart problems
  4. Palpitations, irregular or fast heartbeat
  5. Shortness of breath at any time
  6. Sleep apnea, use of CPAP
  7. High blood pressure
  8. Any circulatory problems
  9. Blood clots or clotting disorders or family history of this
  10. Blood disease (anemia, etc)
  11. Bleeding problems
  12. Any immune problems or disease
  13. Liver disease (hepatitis, jaundice, etc)
  14. Stomach problems (ulcers, etc)
  15. Intestinal problems
  16. Neck or back pain or injuries
  17. Seizures
  18. Headaches
  19. Stroke or temporary paralysis
  20. Current or Past Psychiatric or psychological treatment
  21. Any visual or eye problems, dryness
  22. Glasses or contact lenses
  23. Diabetes
  24. Thyroid problems
  25. Kidney or bladder problems
  26. Any problems during pregnancy
  27. Current or past problems with alcohol or drug abuse
  28. Weight change in the past year
  29. Connective tissue disease (scleroderma, lupus, rheumatoid arthritis)
  30. Cold sores or other herpes infections
  31. Change in any skin growth (moles, etc)
  32. Skin infections, nasal sores, or MRSA infections
  33. Any healing or scarring problem
  34. Cancer of any type
  1. Allergies or unfavorable reactions to any

  2. Have you ever had fillers, BOTOX®, laser, or non-surgical skin tightening
  3. Surgery (if yes, please list type and dates)

  4. Please list any pills or medications taken regularly within the last three years
  5. Do you take aspirin, advil, NSAID's, or any other anti-inflammatory medication?
  6. Do you use a vaginal contraceptive ring, take any hormonal medication, birth control pills, prescription, or over-the-counter medications?
  7. Have you ever smoked cigarettes, Electronic cigarettes, hookah pipes, or marijuana?



  8. Do you drink alcohol?:

  9. When was your last physical exam?
  10. When was your last menstrual period?
  11. Have you been told you have any other diseases not mentioned above?

  • I understand that Dr. Sanders and his staff comply with all HIPAA guidelines. At my request, any staff member will provide me a copy of these.
  • I authorize staff to leave messages on my cell phone or any other number that I designate.
  • I give authorization for Dr. Sanders or any members of his staff to communicate via text message regarding my medical information.
  • I, the patient or responsible parties, authorize release of medical information for the purpose of processing medical claims.
  • I also authorize my insurance company to pay benefits directly to George H. Sanders, M.D., APC.
  • I authorize Dr. Sanders to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
  • I understand that Encino Surgicenter is co-owned by George H. Sanders, MD and Stephen D. Bresnick, MD.
  • I understand that any cosmetic procedure I have with Dr. Sanders requires a $1,000 scheduling deposit which is refundable up to 3 weeks before my agreed upon surgery date.
  • I hereby give permission to George H Sanders, MD and his staff to take photographs of myself with the understanding that such photographs are for confidential clinical records, and that all photographs remain the property of the doctor.
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

HIPAA ACKNOWLEDGEMENT

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Dr. George Sanders, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. 
 
 By checking this box, I acknowledge my understanding the HIPAA Policy and agree with its contents.





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