Please Print & Fax or Bring to Appointment
4 Park Center Court, Suite 100, Owings Mills, Maryland 21117
tel: 410-484-8860 • fax: 410-484-2566
The information on this form is essential for us to review so that we may evaluate your entire suitability and safety for Plastic Surgery. Naturally, all information is strictly confidential. Your time and effort to accurately fill out this form is much appreciated. Thank You!
Date________________________
Patient's Name________________________________________Age_____Date of Birth_________________________
Address____________________________________City____________________State________Zip______________
Phone____________________Married____Single____Widowed____Other____Sex (M)____or (F)____
Cell Phone________________________
Occupation________________________________________Employer_______________________________________
Work Address & Zip____________________________Phone_________________Soc. Security No._______________
Who referred you? |
Your e-mail address:___________________________________ |
____Doctor:______________________________________
____Yellow Pages ( )One Book ( ) Verizon
____Another Patient: Name Please:_________________________________________________________________
____Other:______________________________________________________________________________________
Emergency Contact:_________________________________________Relationship:___________________________
Home Phone:_________________________Work Phone:______________________Other #:_____________________
INSURANCE INFORMATION (If necessary) Name of Insurance Company__________________________________
Policy #____________________________Policy Holder__________________________________________________
Policy Holder's Date of Birth________________________Policy Holder's Soc. Sec. No._________________________
Through What Employer or Company__________________________Other insurance? Please state:_______________
Person Financially Responsible: Patient____Spouse____Parent____Other____________________________________
PRESENT INTEREST
Your Area of Interest in Plastic/Cosmetic Surgery________________________________________________________
ALLERGIES TO MEDICATIONS? Yes____No____Which Ones?_________________________________________
ALLERGIES TO LATEX or ADHESIVE TAPE? Yes____No____Which Ones?_________________________________________
PAST MEDICAL HISTORY
General Health: Good____Fair____Poor____If Not "Good" Please Explain____________________________________
________________________________________________________________________________________________
Do You Smoke? Yes____ No____(How Many Packs A Day?_________For How Long?________________________
PREVIOUS SURGERY (please list, if additional sheet is needed please ask)
Operation, Year, Hospital, City, Surgeon's Name, Anesthesia
________________________________________________________________________________________________
________________________________________________________________________________________________
Complications After Surgery? Yes____No____If No, Explain______________________________________________
________________________________________________________________________________________________
Have you ever had nausea after surgery or a tendency to have motion sickness or get car sick? Yes___ No___
If so please explain. ________________________________________________________________________________
PRESENT HISTORY
Height____________________Weight____________________Date of Last Physical Exam______________________
Name and Address of Family Doctor_________________________________________________________________
Serious Illness? (please list)_______________________________________________________________________
Is there any possibility that you may be pregnant at this time? Yes__________ or No__________
MEDICATIONS you are now taking including blood thinners, aspirin, bufferin, birth control pills, diuretics, tranquilizers, hormones, blood pressure or heart medications, etc.___________________________________________
_______________________________________________________________________________________________
PREOPERATIVE INFORMATION Have you ever had? (Answer Yes or No)
Allergic to Adhesive Tape____________ Form Keloids____________ Bruise/Bleed Easily____________
High Blood Pressure____________ Heart Disease____________ Diabetes____________ Lung Disease____________
Kidney Disease____________ Asthma____________
RELEASE OF INFORMATION: I certify that the information I have reported is correct. I realize that I am fully responsible for payment in full to James E. Vogel, M.D., F.A.C.S. for services incurred. I authorize the release of any necessary medical information in the event of an emergency.
Signature__________________________________________________Date__________________________________
ASSIGNMENT OF BENEFITS: I request the payment of benefits be made directly to James E. Vogel, M.D., F.A.C.S. for services furnished to me. I authorize James E. Vogel, M.D., F.A.C.S. to apply for benefits on my behalf. In the event that insurance payment is not made, I understand that I am fully responsible.
Signature__________________________________________________Date__________________________________