1200 Binz, Suite 1040 * Houston, Texas 77004
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1200 Binz, Suite 1040 * Houston, Texas 77004 Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name: Date: Date of Birth: Referring Physician: Patient Acct #: Attending Physician: Ryan W. Ahern, MD
WAIVER FORM
Your insurance carrier will not cover the service rendered today because this service is not covered under your insurance plan.
PATIENT AGREEMENT
I have read the above statement and understand that my insurance company will not pay for the medical services that will be performed for cosmetic reasons. Therefore, I am accepting full financial responsibility for these services, and I acknowledge that my payment is due on the date of my procedure.
______Patient/Guarantor Signature Date 1200 Binz, Suite 1040 * Houston, Texas 77004 Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name: Date: Date of Birth: Referring Physician: Patient Acct #: Attending Physician: Ryan W. Ahern, MD
Authorization And Release: Taking And Publication Of Photographs, Images, And Audio/Visual Materials (Page 1 of 2)
I hereby authorize Ryan W. Ahern, MD my physician or someone selected or authorized by the Advanced Dermatologic Surgery, P.A. to obtain photographs, images, and/or audio/visual materials of me related to my cosmetic treatment.
I hereby authorized and release any photographs, images, or audio/visual materials taken in the course of my cosmetic treatment to Advanced Dermatologic Surgery, P.A. for use in: medically related publications, in-office patient, education materials; and/or marketing materials. Such uses may be for one or more of the following purposes:
Medical education – (medically-related publications, brochures, slides, letters to be used within the medical community); non-medical education – (slides for lectures to civic groups, social organizations, service organizations, etc); patient education (i.e., photographs used to show prospective surgery candidates comparisons pre- and post- surgery); and/or marketing (to show comparisons before and after surgery to prospective patients utilizing print (such as newspapers ,newsletters , magazines, brochures, handouts, office literature) and/or electronic media (radio, television, Advanced Dermatologic Surgery, P.A. internet website).
The following restrictions apply (optional): ______
I understand that I will not be identified by name as the subject in any photographs, images, or audio/visual materials used for the above authorized purposes. However, I acknowledge and accept that despite reasonable precautions, my identity may be revealed if such photographs, images, or audio/visual materials are distributed and viewed by prospective patients or others individuals who may know and recognize me.
I hereby release my physician, Advanced Dermatologic Surgery, P.A., its personnel and any other persons from liability connected with the taking or use of such photographs, images, or audio/visual materials of which I am a subject, including but not limited to the disclosure of my identity.
I understand that photographs, images, or audio/visual materials of which I am subject shall become the property of Advanced Dermatologic Surgery, P.A. All such photographs, images, or audio/visual materials shall become a part of my medical record and retained in accordance with state regulations. 1200 Binz, Suite 1040 * Houston, Texas 77004 Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name: Date: Date of Birth: Referring Physician: Patient Acct #: Attending Physician: Ryan W. Ahern, MD
Authorization And Release: Taking And Publication Of Photographs, Images, And Audio/Visual Materials (Page 2 of 2)
This authorization and release shall remain in effect until I revoke it in writing.
I grant this authorization and release because I favor the advancement of medical science, public education, and/or the promotion of services for Advanced Dermatologic Surgery, P.A.
I have read this authorization and release, understand its content, and have full capacity to execute it.
Date: ______Procedure: ______
Patient: ______
Patient Signature: ______
Witness: ______
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Date: ______Procedure: ______
Patient: ______
Patient Signature: ______
Witness: ______
If patient is a minor or unable to sign, insert name of patient above and have next of kin, parent or guardian sign below:
______1200 Binz, Suite 1040 * Houston, Texas 77004 Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name: Date: Date of Birth: Referring Physician: Patient Acct #: Attending Physician: Ryan W. Ahern, MD
Signature Relationship to patient COSMETIC QUESTIONNAIRE (page 1 of 2)
What concerns would you like to address today?______What cosmetic procedures have you had before? ______Any history of depression or mental illness?______What cosmetic procedures are you interested in? ______
1. Do you have any medical allergies? Yes No ______
Describe reaction: ______
2. Are you on any medications or hormones? Yes No ______
3. Do you take any over the counter medications on a regular basis? Yes No (Aspirin, antihistamines, etc.) ______
4. Do you have any of the following medical problems? Yes No Yes No Heart disease Lung disease High blood pressure Asthma Diabetes Liver disease Bleeding problems Kidney disease Pulmonary embolus Thrombo phlebitis (vein inflammation) Hepatitis Immune suppression Artificial joints or heart valves Other 1200 Binz, Suite 1040 * Houston, Texas 77004 Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name: Date: Date of Birth: Referring Physician: Patient Acct #: Attending Physician: Ryan W. Ahern, MD
COSMETIC QUESTIONNAIRE (page 2 of 2)
If you answered yes to any of the above, please describe your condition or any medical disorder you may have that is not listed: ______Who is your primary care physician? ______
With any surgery procedure it is very important to relay history of an abnormal bleeding problem. Any abnormal bleeding tendencies can cause complications both during and after surgery.
1. Do you have abnormal or heavy periods? ______1. Do you have recurrent nose bleeds? ______2. Have you had persistent bleeding after tooth extractions? ______3. Do you have a history of anemia (low blood count)? ______4. Do you have a history of easy bruising?______5. Do you have any family members with abnormal bleeding? ______7. Do you have fever Blisters? ______
Medications ( List attached)______1200 Binz, Suite 1040 * Houston, Texas 77004 Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name: Date: Date of Birth: Referring Physician: Patient Acct #: Attending Physician: Ryan W. Ahern, MD