VillanoMD New Patient Paperwork Welcome to VillanoMD We look forward to supporting you on your journey of Timeless Beauty. We are located at 431 NE Revere Ave in Bend, Oregon. If you need help filling out this form, please dial 541.312.3223 and our staff will be happy to assist you. Please NOTE: All fields marked with an asterisk (*) MUST BE completed in order to proceed to the next page and to successfully submit this form. When you reach the bottom of each page click on "Next" to access the next page. Once all pages (there are 6 pages total) have been completed please click on the "Submit" button on the bottom of the final page. Thank you in advance for your help in ensuring an efficient check-in process for our patients and staff.Patient 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*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: How did you find us? Is there someone we can thank for recommending us? AUTHORIZATION FOR DISCLOSURE/RELEASE OF INFORMATIONI authorize VillanoMD 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 VillanoMD'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 VillanoMD.Date* MM slash DD slash YYYY Signature* SURGERIES/YEAR PERFORMED Please list any surgeries and the year performed here. To add lines click on the "plus" circle at right.List MEDICAL HISTORY (MEDICAL DIAGNOSES, CHRONIC ILLNESSES, HIGH BLOOD PRESSURE) Please list any medical diagnoses, chronic illness, or other medically relevant information here. To add lines click on the "plus" circle at right.List CURRENT MEDICATIONS Please list drugs and dosages your are currently taking here. To add lines click on the "plus" circle at right.Drug/Dose ALLERGIES Do you have any medication/drug allergies? Yes No List any medications/drugs that you have had a bad reaction to Do you have any latex or tape allergies? Check which one applies. Latex Tape Neither/not applicable PERSONAL INFORMATIONDo you currently smoke/vape/use nicotine products? Yes No How many years? Have you smoked/vaped/used nicotine products in the past? Yes No How long ago did you quit? 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 any injectables/fillers in the past? Yes No Have you had a bad reaction to local or general anesthesia? Yes No Describe Have you had depression, anxiety, or other mental health issues requiring medical care? Yes No Describe Have you had a diagnosis of body dysmorphic disorder? Yes No Do you bleed easily from cuts or surgery? Yes No Are you prone to scarring? Yes No Are you currently pregnant?* Yes No Not applicable Are you currently breast feeding?* Yes No Not applicable 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 VillanoMD. 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 financial policies and procedures for you. CONSULTATION Surgery Consultation with Dr. Villano A cosmetic surgery consultation with Dr. Villano is scheduled at the time of your initial telephone call. Be advised there is a $250 consult fee. We require a $125 deposit to hold your appointment, with the remaining $125 due on day of consultation with Dr. Villano. This fee 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 aesthetic goals and surgical needs, outline the procedure(s) recommended, and inform you of the related 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 your appointment more than 24 hours prior to the scheduled appointment time, we will retain your $125 deposit as a cancellation penalty. Certified Injector Consultation Please be advised there is a $50 consult fee for your injectables consultation with VillanoMD's Certified Injector. This is collected at the time you book your appointment. This fee will be applied to your first service appointment (fillers and neuromodulators only) booked and completed with VillanoMD's Certified Injector. This consultation is designed for you and VillanoMD's Certified Injector to meet and discuss your aesthetic goals and needs, outline the procedure(s) recommended, and inform you of the related fees. If you are a no-show on the day of your appointment, or do not cancel your appointment more than 24 hours prior to the scheduled appointment time, this $50 fee will be retained as a cancellation penalty. 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, 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 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 Patient signature*Date 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.List Δ
