Home
About
Medical Patient Paperwork

Medical Patient Paperwork

Please fill out our New Patient Form below and provide as much information as possible. If we have any further questions you will be contacted accordingly.

*All fields are required.

Personal Information

Last Name

First Name

Middle Name

Name as it appears on your state-issued ID

Home Address

City

State

Zip Code

Home Telephone

Cell Phone

Work Phone

Other Phone #

Which number should we use to contact you?

HomeCellWorkOther

We make reminders! Would you like to be contacted via phone or e-mail?

PhoneE-Mail

Your E-Mail Address

Birth Date

SSN #

Sex
MaleFemale

Occupation

Photo of Driver's License (please upload a gif, png, jpg or jpeg)

No file selected

Employment Information

Employer Name

Employer Phone Number

Employer Address

City

State

Zip Code

Additional Information

Which procedure would you like to discuss today on your visit? Please specify and describe your situation a little bit below in the boxed area.

Referred by

Appointment Date

Appointment Time

Telehealth Authorization and Release

I hereby consent to communicating online with Dr.

and his/her staff and personnel (hereinafter referred to collectively as “my Doctor”) so as to conduct virtual consultations, telemedicine/telehealth, and any other purpose deemed by my Doctor to be appropriate while I am receiving medical and aesthetic services.

As announced by the US Department of Health & Human Services (“HHS”) on March 17, 2020, I understand my Doctor is now authorized to use non-public facing audio and/or video communication technology to provide telehealth, whether or not related to COVID-19, including HIPAA compliant ZOOM, Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, but my Doctor is not authorized to use public facing technology, such as Facebook Live, Twitch or TikTok.

I accept that even authorized non-public facing third-party applications potentially introduce privacy risks, but my Doctor will enable all available encryption and privacy modes when using these applications.

I understand that I have the right to revoke this authorization in writing at any time, but if I do so it will have no effect on any actions taken prior to my revocation. Unless and until I revoke this authorization, it will exist in perpetuity from the date written below. I understand that I may refuse to sign this authorization and such refusal will have no effect on the medical treatment I receive from my Doctor.

I release and discharge my Doctor and all parties acting under my Doctor’s license and authority from any telehealth medical privacy claims I might otherwise have had prior to HHS’s March 17, 2020 notification. I certify that I have read this Authorization and Release and fully understand its terms.

Patient Signature:

Witness/Physician/Staff:

Patient Name:

Date:

I have read the above Authorization and Release. I am the parent, guardian or conservator of the patient, a minor. I am authorized to sign this consent on the patient's behalf.

Parent/Guardian/Conservator Signature:

Date:

Parent/Guardian/Conservator Name:

Emergency Contact

Name

Relationship

Home Phone

Work Phone

Cell Phone

Parental Signature (Type your full name to sign in field below):

Date

Health Information

Name

Age

Primary Physician

Gynecologist

Date of Last Physical Exam

Date of Last Mammogram

Pants/Dress Size

Bra Size

Height

Weight

Are you taking any medications on a regular basis or any within the past 12 months? (Include Aspirin/Vitamins) (If Yes, please list in box to the right.)
YesNo

Are you taking birth control or using Intrauterine Devices or on Hormones? YesNo

Are you allergic to or ever had any reaction to any medications, drugs or local anesthetic? (Including Novocaine, Xylocaine, Latex, soaps, lotions, tapes, etc.) (If Yes, please list in box to the right.)
YesNo

Have you ever had an operation or been hospitalized for any reason? (If Yes, please provide Date, Reason, and Physician in the box to the right.)
YesNo

How many pregnancies have you had?

How many births have you had?

Have you ever had rheumatic fever, heart trouble, heart murmurs, palpitations, irregular heartbeat, chest pains, high blood pressure, shortness of breath, swelling of the ankles?
YesNo

Have you ever had diabetes, hepatitis, cancer, thyroid disorder, kidney problems, asthma, chronic lung or bronchial disease, or any other serious illness?
YesNo

Have you or anyone in your family ever been diagnosed and/or treated for bleeding disorder, blood clots, excessive bleeding, Deep Venous Thrombosis (DVT), or Pulmonary Embolism?
YesNo

Have you ever had a fractured nose, difficulty breathing, nose bleeds, post nasal drip, hay fever, deviated septum, sinus pain?
YesNo

Have you ever had eye disease, trouble with dryness, soreness, burning, itching, excessive tearing of the
eyes?
YesNo

Have you ever had any psychiatric problems, nervous breakdown, presently or have you ever been under the care of a psychiatrist?
YesNo

Do you have any problems with excessive scarring, or have you ever formed a keloid after being cut? YesNo

Do any diseases run in your family? (Please answer Yes or No. If Yes, use box below to provide details.)
YesNo

Is there any additional health information you feel you may need to discuss with us? (If Yes, please use box below to provide details.)
YesNo

Do you have a problem with alcohol or chemical dependency?
YesNo

Do you use any Nicotine containing products? (i.e.: patches, gum)
YesNo

Do you smoke Cigarettes or Vapor/electronic cigarettes?
YesNo

How many cigarettes or vapor/electronic cigarettes do you smoke?
(Please explain briefly in box below.)

Privacy Practices and Confidential Communications

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1966 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician Certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the above address to obtain a current comp of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

CONFIDENTIAL COMMUNICATIONS

I request that all communications to me (by telephone, mail or otherwise) by St. Louis Cosmetic Surgery, Inc., and/or its staff be handled in the following manner:

For written communications, send to:

First Name:

Last Name:

Address:

Postal Code:

State:

For oral communications, call Telephone Number:

If you are unavailable at this number, may we leave an answering machine or voice mail message? YesNo

Do we have permission to disclose your health information with another person other than yourself? YesNo

If yes, Name:

Relationship:

Patient Signature:

Date of Birth:

This notice of privacy practices form is good for 1 year from when signed.

COVID-19 Informed Consent Agreement

(initial) I, the undersigned patient, consent to an in-person consultation and/or to have my Doctor and/or his/her staff (hereinafter collectively “my Doctor”) perform medical procedures, whether regarded as necessary, elective or aesthetic, during the time of the COVID-19 pandemic and after. I understand in-person consultations and/or having my procedure performed at this time, despite my own efforts and those of my Doctor, may increase the risk of my exposure to COVID-19. I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to my health, and even death. I am also aware of the possibility that the procedure itself, whether performed in my Doctor’s office or in a hospital, may result in a more severe case of COVID-19 than I might have had without the procedure.

(initial) I also understand in-person consultations and/or having my procedure performed at this time increases the risk of my transmission of COVID-19 to my Doctor. This virus has a long incubation period, there may be as yet unknown aspects of its transmission, and I realize that I may be contagious, whether or not I have been tested or have symptoms. To reduce the possibility of COVID-19 exposure or transmission at my Doctor’s office, I accept that my Doctor will implement infection-control procedures with which I must comply, before, during and after my consultation and/or procedure, for my own protection as well as that of my Doctor. I understand my cooperation is mandatory, whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.

(initial) I have informed my Doctor of any COVID-19 testing I or any person living with me during the past 14 days has received, as well as the results of that testing, and if I am tested between now and the date of my procedure, I will immediately provide the results of that testing to my Doctor. I understand my Doctor may require that I be tested, possibly at my own expense and regardless of any prior testing, and that the results of that testing must be satisfactory to my Doctor, before I may receive my procedure. I understand I must honestly disclose this information to avoid putting myself and others at risk.

(initial) All topics above have been discussed with me, and all my questions have been answered to my satisfaction. Being fully informed, I accept the risk of COVID-19 exposure and I will bear the cost of any COVID-19 treatments required. I have been given the opportunity to postpone my in-person consultation and/or procedure until the COVID-19 pandemic is less prevalent, but I choose to have my in-person consultation and/or procedure performed now. If I am the parent, guardian or conservator of the patient, I hold his/her health care power of attorney. I have read this COVID-19 Informed Consent Agreement and am authorized to consent on the patient's behalf.

Patient/Authorized Representative Initials

Patient/Authorized Representative Signature

First Name

Last Name

Date

Notice and Disclaimer. Medical information changes constantly. This COVID-19 Informed Consent Agreement sets forth the current recommendations of The Aesthetic Society, is provided for informational purposes only, and does not establish a new standard of care.

Payment Policy

We strive to provide all of our patients with prompt and excellent medical care and to assist you in the handling of your bill. In order to maintain your account in good standing, our requirements for payment of your account are as follows:

PAYMENT IS EXPECTED FOR ALL OFFICE VISITS, SERVICES, TREATMENTS, AND PRODUCTS AT THE TIME OF EACH VISIT.
ALL CHARGES ARE DUE AND PAYABLE THE DATE THEY ARE INCURRED
We do not accept the theory that legal cases should be settled before payment of the fee is due. ALL CHARGES ARE DUE AND PAYABLE THE DATE THEY ARE INCURRED.

Because our services are rendered to YOU, you are responsible directly to us for settlement of your account within the time limit set. Please feel free to discuss your bill or charges at an early date, to avoid misunderstandings.

It is understood that failure to comply with this agreement would leave St. Louis Cosmetic Surgery, Inc. no alternative but to seek collection action.

The quote that you receive at your consult will include the doctor’s fee, plus OR and anesthesia. Payment of these fees will be due prior to surgery.

We do not accept or file insurance claims. Our services are not covered by insurance.

Signature (Type your full name to sign in field below):

Date

Due to the HIPAA (Health Insurance Portability and Accountability Act) all information must be completed on this form and the following forms. If you have any questions regarding this, anyone in our office will be glad to help you.

Thank you for choosing St. Louis Cosmetic Surgery

Medical Patient Paperwork

Personal Information

Employment Information

Additional Information

Telehealth Authorization and Release

Emergency Contact

Health Information

Privacy Practices and Confidential Communications

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

CONFIDENTIAL COMMUNICATIONS

COVID-19 Informed Consent Agreement

Payment Policy

COVID-19 UPDATE: