1200 Binz, Suite 1040 * Houston, Texas 77004
Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name:
Date of Birth:
Patient Acct #:
Date:
Referring Physician:
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 of Birth:
Patient Acct #:
Date:
Referring Physician:
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 of Birth:
Patient Acct #:
Date:
Referring Physician:
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: __________________________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------------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:
__________________________________________
Signature
__________________________________________
Relationship to patient
1200 Binz, Suite 1040 * Houston, Texas 77004
Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name:
Date of Birth:
Patient Acct #:
Date:
Referring Physician:
Attending Physician:
Ryan W. Ahern, MD
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
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
Yes
No
1200 Binz, Suite 1040 * Houston, Texas 77004
Tel: (713) 528-8882 Fax: (713) 528-8883
Patient Name:
Date of Birth:
Patient Acct #:
Date:
Referring Physician:
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.
1.
2.
3.
4.
5.
Do you have abnormal or heavy periods? ___________________________________________________
Do you have recurrent nose bleeds? ________________________________________________________
Have you had persistent bleeding after tooth extractions? _____________________________________
Do you have a history of anemia (low blood count)? __________________________________________
Do you have a history of easy bruising?_____________________________________________________
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 of Birth:
Patient Acct #:
Date:
Referring Physician:
Attending Physician:
Ryan W. Ahern, MD