Beverly Cosmetic Surgery Institute
Peter Driscoll, MD
PATIENT INFORMATION
Patient Name: ________________________________ ___Date: ________ Date of Birth: ____________ Age: _________
Address: __________________________________________ __City: ___________ State: __________ Zip:____________
Home Phone: _________________ Cell Phone: _________________ _Work Phone #: ___________________________
Social Security #:___________________ _________Driver’s License #:________________________________________
Email Address: _______________________________________Occupation: ___________________________________
RESPONSIBLE PARTY OR SPOUSE INFORMATION
Relationship to patient (circle one): Self
Name:________________
Spouse
Dependent
Other: ________________________
_______Address:______________________Occupation: _______________________
Cell phone: _________________ Work Phone: ____________________ Employer: _______________________________
EMERGENCY CONTACT
Name: _________________________ Relationship to Patient:_________________________Phone:________________
Address: _______________________________________ City: _______ State:_____________Zip:___________________
HOW DID YOU HEAR ABOUT BEVERLY COSMETIC SURGERY INSITIUTE?
Doctor:_________________ Friend:_____________________________Internet/Website:________________________
Magazine:_______________Radio:________________Other:________________________________________________
Reason for today’s visit:__________________________ __________________________________________________
Have you had any other consultations for this procedure? Yes No If yes, who did you see?_____________________
Current Medications: please include prescription, over the counter meds, vitamins and herbals
_____________________________________________________________________________________
PATIENT MEDICAL HISTORY Do you have now, or have had diseases or conditions of (please circle yes or no):
Skin Cancer
Other skin disease
Problems with skin healing
Keloids (scar) after surgery
Skin rash/ Medication
Skin rash/ environmental
Diabetes
Asthma/ Wheezing
Eye Disease
Heart Murmur
Thyroid Problems
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Pacemaker
Yes No
Eye Disease
Yes No
Phlebitis
Yes No
Blood Clots
Yes No
Kidney Problem Yes No
Fainting
Yes No
Liver Disease
Yes No
Arthritis
Yes No
Dizzy Spells
Yes No
Heart Attack
Yes No
Epilepsy/ Seizures Yes No
Skin rash/bandages
Skin rash/ topical Neosporin
Skin rash/ food
Skin rash/ other
Bleeding problems
Swelling hands/feet
High Blood Pressure
Chest Pain
High Blood Pressure
Irregular Heartbeat
Gastrointestinal Disorder
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
List any other disease or condition: _________________________Past Surgeries: ________________________________
Do you smoke? Yes No If yes, how much?_____________ Drink Alcohol? Yes No how much?______________
Have you ever been exposed to HIV (AIDS) or Hepatitis: Yes No
Family Medical History:
Skin cancer: Yes No Relation: ______________
Type of Cancer: _______________________
Other medical problems: Yes No Relation:______________________ Type of Problem:_______________________
FEMALE PATIENTS ONLY: Currently Pregnant: Yes No
Breastfeeding? Yes No Trying to conceive?
Yes No
Using Contraceptives
Yes
No
ACKNOWLEDGMENT/ CONSENT (please initial on each line)
RECEIPT OF NOTICE OF PRIVACY PRACTICES
_____ I, _____________________, have read a copy of Beverly Cosmetic Surgery Institutes Notice of privacy practices.
(This document is available at our front desk)
_______CANCELATION POLICY: If the patient cannot adhere to a scheduled appointment, it is the patient’s responsibility
to call the office and cancel within 24 hours of the scheduled appointment. Beverly Cosmetic Surgery Institute reserves
the right to charge the patient a $50 fee if the patient does not cancel the appointment within 24 hours.
_____RELEASE OF MEDICAL INFORMATION: I do/ do not authorize Beverly Cosmetic Surgery Institute and its designated
representatives to release my medical information to my spouse, parent, guardian, or any other designated person.
Name: ________________________
I do/do not authorize BCSI and its designated representatives to release my medical information to my primary care
physician. If authorized, please provide Name: _____________________________.
_____CONTACT PERMISSION: In the event that BCSI needs to contact you regarding an appointment, lab results,
medication etc. it is permissible to: CIRCLE: A. Leave message B. Speak with spouse or significant other C. Speak with
other family/friend
_____CONSENT TO PHOTOGRAPHY/ VIDEO: I hereby grant permission for Beverly Cosmetic Surgery to take
photographs/videos of me. I understand that all photographs/videos are taken are the property of Beverly Cosmetic
Surgery Institute and I grant permission to use my likeness in a photography/video in any and all of its publications,
including website entries, without consideration or payment. I hereby irrevocably authorize Beverly Cosmetic Surgery
Institute to edit, alter, copy, exhibit and/or publish distribute my photographs/ video and information relating to my
case for the purpose of medical research, educations, & science/ publicizing purposes or for any lawful purpose. In
addition, I waive the right to any compensation arising or related to the use of the photographs/ video and information
relating to my case. I shall not be identified by name. I hereby hold harmless and release and forever discharge Beverly
Cosmetic Surgery Institute from claims, demands, and causes of action which, I mu heirs, representatives, executors,
administrators, or any other persons acting on my behalf may have by reason of this authorization. I further understand
that all photographs/ video are necessary part of planning and evaluating cosmetic and/or reconstructive surgery.
_____ CONSENT TO TREATMENT: I represent to the physician and staff that I am at least 18 years of age or, if not
accompanied by legal guardian. I hereby consent to and authorize examination and treatment by the doctor and such
assistant or staff as may be assigned by the doctor.
_____AUTHORIZATION/ ASSIGNMENT/ FINANCIAL RESPONSIBILITY: I understand that I am responsible for all charges
incurred and that payment is due at the time of services. I further acknowledge that BCSI does not file any claims with
any insurance carrier and all services must be paid out of pocket. I understand there may be a consultation fee for the
initial visit. Should my account become a past due, additional charges may be incurred and all balances must be paid
prior to additional services being rendered. My signature below indicates that I have read and am in agreement with
all statements that I have initiated above.
Signature of Patient/Guardian___________________________________________________Date:___________