Patient Consent Form - Keywest Institute for Plastic Surgery

Please complete and return to the front desk
Last Name _______________ First Name _____________MI ___ Nickname______
DOB ____/____/______ Age ______ Sex____ SSN# ______-_____-______
Relationship Status________Birthplace___________________
Home Address_______________________________APT. #______
City___________State_______Zip_________ Day Phone_______________________
Evening Phone__________________________Cellular Phone____________________
Occupation___________Employer/School______________________How long? _____
Drivers License #_____________________
Which is your preferred contact number? ________________________
E-mail address _______________________Would you like to receive E-mail newsletters
periodically offering special discounts and news? Yes, No.
Any restrictions on contacting you? Yes, No.What restrictions?
Nearest Relative Not Living With You
Name: Last _____________________First____________Relationship ______________
Day Phone _____________ Evening Phone ______________Cell Phone ____________
Emergency Contact(s)
1) Name:
Day Phone___________Evening Phone ______________Cell Phone________________
2) Name: Last ___________________First____________Relationship_______________
Day Phone___________Evening Phone _____________Cell Phone_________________
Getting To Know You
Why did you select our office?
Who referred you to us? If by an ad, which one?
Have you had previous Cosmetic Surgery? When? What?
Have you consulted with another doctor for this procedure? When? With Whom?
Payment Alternatives
Personal checks are accepted at least 10(ten) business days prior to surgery
Mastercard, Visa, Discover and American Express accepted
Payment Financing: In house financing, Care Credit, Advance Care
For All Patients
I, ___________________________represent to the physicians and staff that I am at least
eighteen (18) years of age, or if not, I am accompanied by a legal guardian.
Authorization for Examination: I authorize and consent to physical examination by the
Patient coordinator, the doctor, or any staff of Key West Institute for Plastic Surgery,
designated by the doctor. I acknowledge and recognize that the Patient coordinator and/
or the sum of the staff of Key West Institute for Plastic Surgery, who will or may conduct
a physical examination of me, may not be medically trained persons. Nevertheless, I
agree to be physically examined by the Patient coordinator and/or staff members of Key
West Institute for Plastic Surgery.
I authorize the release of any medical information for the purpose of processing insurance
claims on my behalf. I authorize payments of medical benefits directly to the doctor for
services provided. A copy of the authorization shall be considered as valid as the original.
For all elective, “fee for service” procedures I agree to pay for all services rendered by
this office.
I understand that photography is a necessary part of planning and evaluating cosmetic
and reconstructive surgery. I authorize the taking of photographs at the direction of my
surgeon. These photographs will be used for documentation, peer review, and /or patient
education. I do or do not (circle one) authorize the use of my photographs for marketing
Signature of Responsible Party
Last Name _____________, First______________, MI______
DOB ___/______/________Age_____Sex_____SSN#_____-______-______
Date _____________ Reason for Consultation _______________________________
Please list all medications, supplements, vitamins or herbs you have taken within the last
month. Medication dose, indication. If stopped, when?
Ever taken Metabolife? _____ If so, when last taken? ______
Ever taken Accutane? _______If so, when last taken? ______
*Allergies: Please list all medications, anesthetics, tapes, or other agents (latex) to which
you have had an adverse reaction
Approximate date__________
All hospitalizations and/or operations and dates:
Check any of the following diseases, which you have or have had:
High Blood Pressure-
Y, N
Stroke / Heart Attack/TIA’s
-Y, N. If yes, when?__________________
Congenital Heart Disease-Y, N Heart Valve Disorder(s)-Y, N
Murmur-Y, N
Rheumatic Fever-Y, N
Chest Pains-Y, N
-Y, N
Irregular/Fast Heartbeat
-Y, N
Seizure Disorder/Epilepsy-Y, N
Shortness of Breath
-Y, N
Y, N
Emphysema-Y, N
Bronchitis-Y, N
Pneumonia-Y, N
Tuberculosis-Y, N
Sleep Apnea-Y, N
-Y, N
Cancer-Y, N
Blood Disorders/ Hemophilia-Y, N
Blood Clots (DVT)
-Y, N
Easy Bruising /Excessive Bleeding-Y, N
Diabetes- Y, N
Liver Disease/Hepatitis/Jaundice
-Y, N. If yes, what? ______________
Thyroid Disorder-Y, N
Reflux /Hiatal Hernia
-Y, N
Y, N
Anxiety-Y, N
Mental Disorders
-Y, N. If yes, what? ____________
Dry Eye Syndrome-
Y, N
Y, N
Cataracts-Y, N
Fainting Spells
-Y, N
Herpes/Genital-Y, N
History of IV drug use-Y, N
Please detail those listed above or any other medical conditions not listed
Please list any medical conditions that run in your family:
Blood clots, Bleeding Disorders, Breast Cancer. Other:
Have you or any family member had an unfavorable reaction to anesthesia?
Yes, No. If yes, what? ____________________________________
Physicians who care for you _________________________________________
Specialty________________ Phone______________
Latest mammogram (date) ___________________or N/A
Latest EKG (date) ________________ or N/A.
Number of pregnancies____, Live births ____, Ages of children
_______________________________, Any more planned? _____
Do you drink alcohol? _______ If so, how many drinks per week? _________
Do you smoke? _________ If so, how many packs per day? _______,how many
years____ if you quit, when? ________________
Do you now, or have you ever used ‘street drugs’? _________________
Height __________,Weight _________, How much weight loss ________, or gain
________, have you had over the last 2 years?
Do you wear eyeglasses? ______Do you wear contact lenses? ________
Do you wear removable dental appliances/dentures? _______
Do you have any disease, condition or problem not listed that the doctor should know
about? If yes, explain
I have read (or have had read to me) the above medical information listing and I
hereby certify that the information I have provided is correct, and to the best of my
Sign: ______________________________Date: _______________
Patient Consent Form
Use and Disclosure of Health Information Protected under HIPPA
Pursuant to the information contained in the notice of Privacy practices, I give
permission for the use and disclosure of Protected Health Information (PHI) in
order to carry out Treatment, payment and Healthcare Operations (TPO).
I am aware that I have the right to review the Notice of Privacy Practices prior to
signing this consent, Should the Notice of Privacy Practice be revised, I am aware
that I may obtain a copy of the revised form by contacting the medical Directors of
this facility.
I give my consent for this organization to contact me by calling my home or other
designated location in order to leave a message mechanically or with another
person or to speak to me directly regarding any matter, which may help with the
conduct of Treatment, Payment, and Healthcare Operations (TPO).
I hereby consent to the use and disclosure of my PHI for the purpose of Treatment,
Payment, and Healthcare Operations (TPO). The consent is good until revoked in
writing, except to the extent that disclosure has been made in reliance upon my
prior consent.
Services are provided without regards to sex, race, color, religion, national origin, or
Patient’s Name: ________________________________________________________________
Patient’s Signature: ____________________________________________________________
If applicable, Legal Guardian: ___________________________________________________
Date: ______________________________
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