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Patient Information
Last Name
First Name
M.I.
Date:
Reason for today's visit:
Social Security #
Date of Birth
Age
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Legally Separated
Race
Asian
Decline to Specify
White
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Other Race
Ethnicity
Decline to Specify
Hispanic/ Latino
Not Hispanic/ Not Latino
Unknown
Mailing Address
City
State
Zip Code
Email
Physician You Are Seeing Today
Hawner
Employment
Active Duty
Full-Time
Not Employed
Part-Time
Retired
Self
Where do you work?
What is your occupation?
Preferred Language
Student
Full-Time
Part-Time
Emergency Contact not living with you (Relative, Neighbor, or friend)
Relationship
Emergency contact home phone #
Cell phone #
Other Phone #
How did you hear about hawner plastic surgery?
Family/Friend
TV
Radio
Newspaper
Yellow Pages
Doctor
Other
Patient Home Phone #
Patient Cell Phone #
Patient Work #
Patient D.L. #
Local Pharmacy
Address
PERSON RESPONSIBLE FOR THE BILL (ONLY APPLICABLE IF OTHER THAN THE PATIENT)
lAST nAME
First Name
M.I.
Relationship to patient
Mailing address
City
state
zip code
Home phone #
cell phone #
Work phone #
Ext.
INSURANCE INFORMATION
PRIMARY INSURANCE COMPANY
POLICY #
ADDRESS
GROUP #
POLICY HOLDER NAME
RELATIONSHIP TO PATIENT
EFFECTIVE DATE
DATE OF BIRTH
SEX
SOCIAL SECURITY #
eMPLOYER
OTHER INSURANCE COMPANY
POLICY #
ADDRESS
GROUP #
POLICY HOLDER NAME
RELATIONSHIP TO PATIENT
EFFECTIVE DATE
DATE OF BIRTH
SEX
SOCIAL SECURITY #
EMPLOYER
MEDICAL INFORMATION
Referring Physician
City
nAME
PRIMARY CARE PHYSICIAN
CITY
WEIGHT OF PATIENT
HEIGHT OF PATIENT
I. PAST MEDICAL HISTORY
MEDICAL HISTORY (DO YOU HAVE ANY OF THE FOLLOWING)
Asthma
Arthritis
STDs
Hypotension
Epilepsy
Diabetes
Emphysema (COPD)
Heart Disease
Atrial Fibrilation (Irregular Heartbeat)
Coronary Artery Disease
Hepatitis
High Cholesterol (Hypercholesterolemia)
High Blood Pressure (Hypertension)
HIV
Stroke
Thyroid Disease
Hyperthyroidism
Hypothyroidism
Other
Past surgical history
CURRENT MEDICATIONS
Current over-the-counter medications (include supplements)
II. MEDICATION ALLERGIES
SPECIFY
III. SOCIAL HISTORY
DRUG USE
ALCOHOL USE
None
Less than 1 drink per day
1-2 drinks per day
3 or more drinks per day
smoking status
Current every day smoker
Current some days smoker
Former smoker
Never smoked
do you exercise?
Yes
No
exercise status
Exercise once per week
Twice per week
Three to four times per week
Five or more times per week
IV. REVIEW OF SYSTEMS (Do you have any problems in the following areas? Check all that apply)
1) General Health
Normal
Fever
2) Eyes
Normal
Blurred Vision
3) Ears, Nose Mouth, Throat
Normal
Hearing Loss
4) Cardiovascular
Normal
Chest Pain
Respiratory
Normal
Short of Breath
Hematologic/ Lymphatic
Normal
Free Bleeder
8) Musculoskeletal
Normal
Weakness
9) Integumentary (skin/Breast)
Normal
Tumors
10) Neurologic
Normal
Numbness
11) Genitourinary
Currently Pregnant
HAWNER PLASTIC SURGERY ASSOCIATES FINANCIAL POLICY AND PATIENT AUTHORIZATION
PLEASE CHECK THE FOLLOWING LINES. LEAVE BLANK IF NOT APPLICABLE.
I assign Medicare benefits payable to Hawner Plastic Surgery Associates. I understand that I am responsible for deductible and coinsurance.
I assign insurance benefits payable to Hawner Plastic Surgery Associates and I understand that if my insurance company does not pay, that I am responsible for payment. I am financially responsible for my deductible and coinsurance.
I give permission for Hawner Plastic Surgery Associates to render care that the physician deems medically necessary, such as medical treatment and/or minor surgery.
I do hereby authorize Hawner Plastic Surgery Associates to release pertinent information for the following reasons: to physicians for continuing care, to my insurance company or administrator for the processing of claims, and as allowed by law.
I do hereby authorize Hawner Plastic Surgery Associates and Dr. Philip P. Hawner to use my photographs for the purpose of illustration and/or education. I understand that these photos may be used for the photograph book or the internet. I have been informed that these pictures may be viewed by individuals or groups of individuals in teaching or promotional use; in slide format, publications or electronic media. I understand that these photographs may portray my preoperative appearance, intra-operative surgery or post operative results. I also understand that no identification will be used with these photographs, but that they may be viewed by persons who will recognize me and be able to identify me.
Hawner Plastic Surgery Associates is required by Federal and State law to maintain the confidentiality of your protected health information (PHI). This includes demographic information, as well as diagnosis, treatment plans and results. The law is effective April 14, 2003 and will remain in effect until it is replaced by law or by Hawner Plastic Surgery Associates. Upon any change the updated information will become available upon request.
I hereby acknowledge that this agreement will remain in force until i notify hawner plastic surgery associates of any changes.
Yes
No
Patient Signature
date
HIPPA DIRECTIVE FORM - Please list the persons who are allowed to have access to your protected health information below.
name of person
date of birth
relationship
all/restricted
name of person
date of birth
relationship
all/restricted
please check the methods that hawner plastic surgery may contact you.
Home Telephone
Work Telephone
Cell Phone
Email
Text Message
Regular Mail
Voice Mail
