RESPONSIBLE PARTY INFORMATION
Is it okay with you to send a thank you note to the person who referred you to us?:
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?
- 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.