All fields marked with an asterisk (*) are requiredPatient Name* PATIENT INFORMATIONREASON FOR TODAY'S VISIT*Date of Birth* MM slash DD slash YYYY Gender Male Female Marital Status Married Single Widowed Divorced Phone (Home)*Phone (Work)Ext. Phone (Cellular)Address* City/State* Zip* Email* May we send you updates and information regarding our practice? Yes No May we leave a telephone message? Yes No Notes on preferred method of contact May we email you product/service special offers, seminar information, or newsletters at this address? Yes No REFERRED BY: Referred by Research Magazine Another Person Another Business Seminar None Who recommended us? Relative Friend Another patient Employee Physician What is the name of the person who recommended you? How did you find us? Website Search engine (Google, Bing, Yahoo, etc...) What is the name of the business? AUTHORIZATION FOR DISCLOSURE/RELEASE OF INFORMATIONI authorize Villano|MD to disclose complete information concerning medical finding and treatment of the undersigned, from the initial office visit until date of the conclusion of such treatment, to those individuals who, in Villano|MD's determination, are required to receive such information for the purpose of medical treatment, medical quality assurance, peer review, and if applicable to process the insurance claim for services rendered at Villano|MD.Date MM slash DD slash YYYY Signature* PREVIOUS SURGERIES OR SERIOUS ILLNESSESTYPE YEAR COMPLICATIONS? TYPE YEAR COMPLICATIONS? TYPE YEAR COMPLICATIONS? CURRENT MEDICATIONSDrug/Dose ALLERGIESDo you have any drug allergies? Yes No List any medications that you have had a bad reaction to Do you have any skin product or food allergies? Yes No List any products/foods that you have had a bad reaction to PERSONAL INFORMATIONHeight Current Weight Recent Weight Loss/Gain? Gain Loss None How much weight? Do you currently smoke? Yes No How many packs? How many years? Have you smoked in the past? Yes No How long ago did you quit smoking? Do you drink Alcohol? Yes No How much? How often? HAVE YOU HAD ANY SERIOUS ILLNESSES OF THE FOLLOWING?Please check. Brain Nose Heart Blood Extremities Eyes Cancer Ears Lungs Abdomen Urinary Nervous Diabetes Reproduction Other Please elaborate on the above illnessesHISTORYHave you had (Injected filler, Collagen, etc.) injections? Yes No Last injection? MM slash DD slash YYYY Have you had Botox/Dysport injections? Yes No Last injection? MM slash DD slash YYYY Have you had facial surgery? Yes No Type? Date? MM slash DD slash YYYY Have you ever had laser resurfacing? Yes No Type? Date? MM slash DD slash YYYY Have you ever had a chemical peel or dermabrasion? Yes No Type? Date? MM slash DD slash YYYY Have you had a bad reaction to local or general anesthesia? Yes No Explain? Have you had significant emotional problems? Yes No Explain? Have you had psychiatric care? Yes No Explain? Have you had a diagnosis of body dysmorphic disorder? Yes No Explain? Have you seen other plastic surgeons about this same concern? Yes No Explain? Do you have high blood pressure? Yes No Explain? Do you bleed easily from cuts or surgery? Yes No Explain? Do you form large scars or keloids? Yes No Explain? Do you have frequent infections, boils or canker sores? Yes No Explain? Do you have Glaucoma? Yes No Explain? Females:Are you currently pregnant? Yes No Have you ever been pregnant? Yes No How many times? Live births? Are you planning more children? Yes No Are you currently breast feeding? Yes No Would you like to be contacted by our Medical Aesthetician about non-surgical procedures and treatments? Yes No I hereby consent to be examined and treated by Michael E. Villano, MD, and I certify that the above information is correct.Date MM slash DD slash YYYY SIGNATURE OF PATIENT OR SPOUSE OR RESPONSIBLE PARTY* Patient name Financial Policy Thank you for choosing Villano|MD for your cosmetic needs. Our goal is to make your experience a pleasant one. For your convenience, and to avoid any future confusion, we would like to outline our policies and procedures for you. CONSULTATION A cosmetic consultation is scheduled at the time of your initial telephone call. Be advised there is a $200 consult fee, which will be applied to your surgery fee once you have booked. This consultation is designed for you and Dr. Villano to meet and discuss your surgical needs, outline the procedure, and inform you of the fees. If insurance is involved, there will be an office visit charge. Please note, if you do not show up for your scheduled appointment or do not cancel within 24 hours, we reserve the right to charge a $35 cancellation fee. SCHEDULING After your consultation, if you decide to go ahead with surgery you will work with our patient care coordinator to select a date for your surgery. PRE-PAYMENT There is a $500 or 10%, whichever is greater, scheduling fee deposit required before the date selected can be reserved exclusively for you. This is a non-refundable deposit. This fee is used to cover the booking and scheduling expenses involved with your surgery. This amount will be deducted from your total cost. PRE-OP VISIT Prior to surgery, preferably two (2) weeks, you will meet with the medical assistant and Dr. Villano. Our medical assistant will explain all pre-operative instructions, order lab tests required, review your surgical procedure and post-operative limitations with you, and give you your post-operative prescriptions with instructions for their use. Post-operative appointments are scheduled at this time. Any questions you may have will be answered at this consult. FINAL PAYMENT Two (2) weeks prior to surgery, the remaining balance on your account is due. We accept: Visa, Mastercard, Money Orders, Cashiers Checks. We are unable to accept personal checks within two weeks for surgery payment. CANCELLATION POLICY If, for any reason, medical or personal, you cancel two weeks or less prior to your scheduled surgery date, fees will be charged as follows: Two (2) weeks prior to surgery — 10% or $500, whichever is greater, of your surgery fee for expenses incurred. One (1) week prior to surgery — 25% of surgical fee One (1) day (24 hours) prior to surgery — full surgical fee If you have any questions about our Financial Policy, please contact us. Our staff will be happy to assist you. Please sign and date.Date MM slash DD slash YYYY Financial Guarantor Signature* CONSENT TO TAKING AND PUBLICATION OF PHOTOGRAPHS By my signature below, I hereby consent to before and after surgery photography for the purpose of documenting my plastic surgery in my medical records maintained in the ordinary course of business by Michael E. Villano, MD, LLC. In addition, by checking the appropriate box below, I grant or deny additional limited use(s) of my photographs. For the additional uses, I understand that my name will not be revealed and my photographs may be appropriately edited to maintain anonymity. Photographs used may be cropped as needed to focus on the area of surgery.Show my photographs to other patients in Dr. Villano's office. Yes No Post my photographs on Dr. Villano's website, or web pages in plastic surgery sites displaying Dr. Villano's photos. Yes No Use my photographs to illustrate lectures and presentations to an audience of medical professionals, and to illustrate scientific journal articles or books for medical professionals. Yes No Use my photographs to illustrate newspaper and magazine articles featuring Dr. Villano, or to illustrate presentations or lectures by Dr. Villano to the general public. Yes No All photographs will be taken only with the approval of Dr. Villano, and under such conditions and at such times as may be approved by Dr. Villano. Photographs may be taken by Dr. Villano, or by an employee or photographer selected by him who has signed a confidentiality agreement concerning patient medical records.NAME OF PATIENT SIGNATURE OF PATIENT OR GUARDIAN (IF PATIENT IS UNDER 18)* HIPAA ACKNOWLEDGMENT AND CONSENT I understand that Michael E Villano, MD (referred to below as "This Practice") will use and disclose health information about me. I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand and agree that This Practice may use and disclose my health information in order to: make decisions about and plan for my care and treatment; refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment; determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and perform various office, administrative and business functions that support my physician's efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care. I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in waiting/reception area. I acknowledge that I have been informed that at times, new information about the practice may be promulgated via e-mail. I have the right to refuse receiving this information at any time by notifying the practice in writing. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests. By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.Date MM slash DD slash YYYY PatientDate MM slash DD slash YYYY Patient representativeDescription of Representative's Authority PATIENT REFERRALS RIGHTS Every patient has a choice when referred to a facility for a diagnostic test or health care treatment or service. As a patient you may receive the diagnostic test or health care treatment or service at a facility other than the one recommended by Dr. Villano. If you would like to be seen at a facility other than the facility recommended by Dr. Villano, you may request information regarding alternative facilities at the front desk. You may also speak to Dr. Villano. If you choose to have the diagnostic test, health care treatment or service at a facility different from the one recommended by Dr. Villano, you are responsible for determining the extent of coverage or the limitation on coverage for the diagnostic test, health care treatment or service at the chosen facility. Δ
