RESPONSIBLE PARTY INFORMATION
HAVE YOU HAD OR DO YOU STILL HAVE :
- Cold or cough within the last two weeks
- Breathing problems (asthma, etc)
- Chest pains or angina, or heart problems
- Palpitations, irregular or fast heartbeat
- Shortness of breath at any time
- Sleep apnea, use of CPAP
- High blood pressure
- Any circulatory problems
- Blood clots or clotting disorders or family history of this
- Blood disease (anemia, etc)
- Bleeding problems
- Any immune problems or disease
- Liver disease (hepatitis, jaundice, etc)
- Stomach problems (ulcers, etc)
- Intestinal problems
- Neck or back pain or injuries
- Stroke or temporary paralysis
- Current or Past Psychiatric or psychological treatment
- Any visual or eye problems, dryness
- Glasses or contact lenses
- Thyroid problems
- Kidney or bladder problems
- Any problems during pregnancy
- Current or past problems with alcohol or drug abuse
- Weight change in the past year
- Connective tissue disease (scleroderma, lupus, rheumatoid arthritis)
- Cold sores or other herpes infections
- Change in any skin growth (moles, etc)
- Skin infections, nasal sores, or MRSA infections
- Any healing or scarring problem
- Cancer of any type
- Allergies or unfavorable reactions to any
- Have you ever had fillers, BOTOX®, laser, or non-surgical skin tightening
- Surgery (if yes, please list type and dates)
- Please list any pills or medications taken regularly within the last three years
- Do you take aspirin, advil, NSAID's, or any other anti-inflammatory medication?
- Do you use a vaginal contraceptive ring, take any hormonal medication, birth control pills, prescription, or over-the-counter medications?
- Have you ever smoked cigarettes, Electronic cigarettes, hookah pipes, or marijuana?
- Do you drink alcohol?:
- When was your last physical exam?
- When was your last menstrual period?
- Have you been told you have any other diseases not mentioned above?
Is it okay with you to send a thank you note to the person who referred you to us?:
- 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.