Dr. Brian K. Howard, M.D.
Patient Registration
Today’s Date: _________________
Welcome to our office. We are committed to providing the best, most comprehensive care possible. We encourage you to ask questions.
Please assist us by providing the following information. All information is confidential and is released only with your consent.
Patient Name: _________________________________
Social Security #: ______________________________
Home Address: ________________________________
Mailing Address (if different): ____________________
Home Telephone: ( ) _________________________
Occupation: __________________________________
Employer’s Name: _____________________________
Date of Birth: __________________ Age: _______ Sex: M F
Driver’s License #: _____________________________________
City/State: _________________________ Zip: ______________
E-Mail Address________________________________________
Cell Telephone: (___)__________________________________
Work Telephone: (___)__________________________________
City/State: _________________________ Zip:___________
Spouse’s Name: __________________________________ Address: __________________________________________
Employer’s Name & Address: __________________________________________________________________________
Home Telephone: ( ) ____________________________ Work Telephone: (___)________________________________
Parent if Patient is a Minor: __________________________________ Date of Birth: _________________ Age: _______
Social Security #: _________________________________ Driver’s License #: __________________________________
Home Address: ___________________________________ City/State: _________________________________________
Mailing Address (if different): __________________________________________________________________________
Home Telephone: ( ) _____________________________ Work Telephone: ( ) _______________________________
Occupation: ______________________________________ Emloyer’s Name: ___________________________________
Employer’s Address: _______________________________ City/State: _________________________ Zip: __________
Does the child live with both parents? YES _____ NO _____
Notify in Case of Emergency: _______________________________________________ Relationship: ______________
Home Telephone: ( ) _____________________________ Work Telephone: ( ) _______________________________
Nearest Relative (Not living with you): _______________________________________ Relationship: ________________
Home Telephone: ( ) _____________________________ Work Telephone: ( ) ________________________________
Whom May We Thank for Referring You to Our Practice? ________________________________________________
Financial Information (Person responsible for fees)
Name: __________________________________________ Relationship: ________________________ DOB: ________
Address: ________________________________________ City/State: _________________________________________
Primary Insurance
Insurance Company: ______________________________ Subscriber Name: ____________________________________
Subscriber’s Social Security #: ______________________ Relationship to Patient: _______________________________
Secondary Insurance
Insurance Company: ______________________________ Subscriber Name: ____________________________________
Subscriber’s Social Security #: ______________________ Relationship to Patient: _______________________________
Were you injured on the job? Yes_____NO_____________Have you informed your employer? Yes______NO__________
HISTORY FORM
The following information is requested to give you the best care and
treatment possible. Please answer as thoroughly and honestly as possible.
Full name______________________Age____Birth Date_______Today’s Date______
Reason for Today’s Visit___________________________________________________
MEDICAL HISTORY: Check any and all that apply.
High blood pressure
Abdominal bleeding/stomach ulcers
Heart attack /stroke/fainting spell
Hepatitis/jaundice
Chest pain/tightness
Blood transfusion
Shortness of breath
Blood clots
High cholesterol/triglycerides
Cancer
Irregular heart beat
Seizures
Heart murmur/rheumatic fever
Scar or healing problems
Lung problems/asthma/tuberculosis
Use accutane or steroids in last year
Diabetes
Are you pregnant currently
Psychiatric care (current or past)
Dry or burning eyes
Kidney problems
Thyroid problems
Bleeding disorders
Other medical conditions or admissions
Ankle swelling
Stomach acid regurgitation
PRIOR SURGERY Use space below as needed.
Year Name of operation
Type of anesthetic, if known Problems?
CURRENT MEDICATIONS-List all drugs and doses. Include all herbal supplements, vitamins,
over-the-counter-medications, and anti-inflammatory drugs. Use space below as needed.
Drug
Dosage
How
often
DRUG ALLERGIES-Include allergies to latex or tape/adhesives please.
Drug
Reaction
Do you wear contact lenses, glasses, hearing aid, or dentures? _______________
SMOKING Do you smoke? □ Yes □ No How much?______________________
Primary Care Physician (name)____________________Last date seen_________
I certify that all information is true and accurate.
Patient signature (parent if patient is a minor)______________________________
For Nurse Use Only:
 Any History of Cold Sores?
Yes/No
G=
P=
Doctor notes—please do not write in this area.
-/+ Hx Cancer:
O2 Sat_____
BP________
BMI________
______ @ 75
HR________
KG_________
______ @ 100
Temp______
Weight______
-/+ MMG:
-/+ Breastfed
-/+ More Children
Bra Size:
Height_______
Dr. Signature
Dr. Brian K. Howard, M.D.
Areas of Interest Questionnaire
We offer a full range of cosmetic and reconstructive procedures. Please circle all
that you are interested in learning more about.
Name__________________________ Today’s Date______________________
Botox
Facelift
Lip enlargement
Breast augmentation
Spider Veins
Chin implant
Breast lift
SmartLipo
Sculptra
Breast reconstruction
Eyelid tuck
Fraxel
Breast reduction
Obagi
Rhinoplasty
Brow lift
Chemical peels
Liposuction
Laser hair removal
Laser treatment
Skin cancer
Skin care
Microdermabrasion
Tummy tuck
Please list any other areas of interest not listed above
________________________________________________________
________________________________________________________
________________________________________________________
Brian K. Howard, M.D.
Financial Policy
Patient__________________________________________
Payment is due in full at the time service is provided.
Cosmetic Surgery: All cosmetic services are to be paid in full two weeks prior the surgery date. A non-refundable $500 scheduling
fee is required to schedule your surgery date. Should you choose to reschedule your surgery for any reason after it has been scheduled,
there will be an additional charge of $250.00. Your history and physical and your pre-operative photos are a part of your total surgical
charge. Canceling your surgery less than one week prior to the scheduled date for any reason will result in an additional 1500.00 nonrefundable fee to cover this time and expense to North Fulton Plastic Surgery and Dr. Brian Howard, in addition to the $500 scheduling fee.
If a surgical product has been ordered for your procedure and needs to be returned, there will be additional charges to cover shipping and
handling of these items. This fee is the responsibility of the patient.
I have read, understand, and agree to the above financial policy for payment of professional fees. The patient is ultimately responsible for
all professional fees.
Signature: ___________________________________________________________ Date: ___________________________
Insurance: As a courtesy, we bill most insurance carriers for you if proper paperwork is provided to us.
We will also bill most
secondary insurance companies for you. Co-payments and deductibles are due at the time of service. If an insurance carrier has not paid
within 60 days of billing, professional fees are due and payable in full from you. If an insurance company indicates that some fees are
above the “usual and customary”, please understand that most physician’s fees are above the rate which insurance companies choose to
pay. That rate is most often lower than the current fees normally charged by any physician. We use many sources to determine the
appropriateness of our fees. Any care not paid for by your existing insurance coverage will require payment in full at the time services are
provided or upon notice of insurance claim denial.
Insurance Surgery Fees: Your carrier may require prior authorization.
Our office will call your insurance carrier to obtain prior
authorization for your surgery and also verify eligibility and benefits. After benefits have been determined for the surgery, we will require
your coinsurance and/ or deductible payment in full prior to your surgery date. If prior approval is denied by your insurance carrier, the
surgery will be cancelled until other financial arrangements can be made. If a surgical product has been ordered for your procedure and
needs to be returned, there will be a charge of $25 to cover shipping and handling. This fee is the responsibility of the patient.
Medicare Patients: We will bill Medicare for you. All co-payments or deductibles are due and payable at the time service is
provided. At the beginning of each calendar year, you will be required to pay your deductible in full prior to being seen.
Medicare Patients: Signature on File: I, _______________________________, request payment of authorized Medicare
benefits be made on my behalf to North Fulton Plastic Surgery, P.C., for any services furnished me by the provider. I authorize any holder
of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine
these benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical
information necessary to pay the claim. If “other health insurance” is indicated in Item 9 of HCFA-1500 form or elsewhere on other
approved claim forms or electronically submitted claims, my signature authorized releasing of the information to the insurer or agency
shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as full
charge and the patient is responsible for the deductible, coinsurance or non-covered services. Coinsurance and the deductibles are based
upon the charge determination of the Medicare carrier.
Signature: _________________________________ Date: ____________________________
Assignment of Insurance Benefits:
Patients with insurance please read and sign below.
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private and/or auto insurance,
and any other health plans, to Dr. Brian K. Howard, P.C. This assignment will remain in effect until revoked by me in writing. A photocopy
of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not
paid by said insurance. I hereby authorize an assignee to release all information necessary to secure payment.
Signature: ___________________________________ Date: ___________________________
I have read, understand, and agree to the above financial policy for payment of professional fees. The patient is ultimately responsible for
all professional fees.
Signature: ___________________________________ Date: ___________________________
RELEASE OF MEDICAL RECORDS CONSENT
Dr. Brian K. Howard, M.D.
1357 Hembree Road
Building B, Suite 200
Roswell, GA 30076
Telephone: 770-619-9566
Fax: 770-619-9597
Dr. Brian K. Howard, M.D. is requesting the records of _____________________
to be sent or faxed to his office as soon as possible. You will find the appropriate
signatures below. Thank you for your help in this matter.
I give my permission to send my records to the office of Dr. Brian K. Howard.
Signed:__________________________________Date:_____________________
Social Security #:_______________________
Date of Birth:__________________________
Date of Service:____________________________
AUTHORIZATION FOR RELEASE
OF PATIENT PHOTOGRAPHS FOR DR. BRIAN K. HOWARD, M.D.
Name
Address
(street address, city, state and zip code)
I consent to the taking of photographs by Dr. Brian K. Howard, M.D. or his designee of me or parts of my body in connection with
the plastic surgery procedure(s) to be performed by Dr. Brian K. Howard, M.D.
I authorize Dr. Brian K. Howard, M.D. or one of his/her associates to publish these photographs on (please initial):
____ website drbrianhoward.com and/or ilikewendy.com
____ any other associated website with Dr. Brian K. Howard, M.D.,
____ office before and after photo album
I provide this authorization as a voluntary contribution in the interests of public education and marketing. I understand that such
photographs shall remain the property of Dr. Brian K. Howard, M.D. and may be released by Dr. Brian K. Howard, M.D. for the
limited purpose of including them in any print, visual or electronic media, specifically including, but not limited to, medical journals
and textbooks, for the purpose of informing the medical profession or the general public about plastic surgery procedures and
methods.
Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the
photographs may portray features that will make my identity recognizable.
I understand that I may refuse to authorize the release of any health information and that my refusal to consent to the release of
health information will prevent the disclosure of such information, but will not affect the health care services I presently receive, or
will receive, from Dr. Brian K. Howard, M.D.
I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand
that I have the right to revoke this authorization in writing at any time, but if I do so it won’t have any affect on any actions taken
prior to my revocation. If I do not revoke this authorization, it will expire twenty years from the date written below.
I understand that the information disclosed, or some portion thereof, may be protected by state law and/or the federal Health
Insurance Portability and Accountability Act of 1996 (“HIPAA”).
I release and discharge Dr. Brian K. Howard, M.D. and all parties acting under their license and authority from all rights that I may
have in the photographs, videotapes or case histories and from any claim that I may have relating to such use in publication,
including any claim for payment in connection with distribution or publication of these materials in any medium.
I certify that I have read the above Authorization and Release and fully understand its terms and grant this consent as a voluntary
contribution in the interest of public education.
___________________________________
Signature
__________________________________
Date
I have read the above Authorization and Release. I am the parent, guardian, or conservator of
, a minor. I
am authorized to sign this authorization on his/her behalf and I give this authorization as a voluntary contribution in the interest of
public education.
___________________________________
Signature
__________________________________
Date
Witness Signature
Date
DR. BRIAN K. HOWARD, M.D.
SURGERY RISKS FOR SMOKERS and NICOTINE
EXPOSED PATIENTS
PATIENT: _________________________________
Dr. Howard and his staff have advised me that I must not smoke, take any nicotine substitutes, or be
exposed to secondhand smoke for a minimum of four weeks before and four weeks after surgery.
It has been explained to me that the risks of surgery are significantly greater if I do smoke, take any
nicotine substitutes, or am exposed to any secondhand smoke during this time period, and that I may still
experience unfavorable effects of nicotine or smoke even if this eight-week exposure period is strictly
followed.
There is a greater risk in smokers for bad scarring, hematoma formation, intraoperative bleeding,
poor or delayed healing, hair loss, sloughing of the skin and deeper tissues (skin and tissue loss,
which can be significant), infection, chronic pain syndromes, increased or prolonged bruising,
hyperpigmentation, heart attack, stroke or death, and resulting deformity.
I ACKNOWLEDGE THAT I HAVE READ EACH AND EVERY LINE OF THE ABOVE AND FULLY
UNDERSTAND THE INFORMATION ABOVE. I HAVE HAD AN APPROPRIATE CHANCE TO
DISCUSS ANY OF THE INFORMATION CONTAINED AND ALL OF MY QUESTIONS HAVE
BEEN FULLY ANSWERED. I FULLY UNDERSTAND THE RISKS AND WISH TO PROCEED
WITH SURGERY.
I HAVE ASSURRED DR. HOWARD AND HIS STAFF THAT I HAVE STOPPED SMOKING, USING
NICOTINE SUBSTITUTES, AND EXPOSURE TO SECONDHAND SMOKE IN PREPARATION FOR
MY SURGERY, AND THAT I WILL STRICTLY ADHERE TO THE ABOVE GUIDELINES OR ELSE
INFORM HIS OFFICE AND CANCEL MY SURGERY.
Patient Signature: ________________________________
Witness Signature: _______________________________
Date: _____________________
Brian K. Howard, M.D., F.A.C.S.
To My Patients:
Our goal is to provide the optimal result with your surgery. However,
operative revisions may occasionally be required. As you know, plastic
surgery is both an art and a science. Human tissue varies, and your healing
is not always predictable. If you have problems with wound healing or
experience other conditions, which do not allow for optimal healing, a
surgical revision may be necessary. In this instance, the surgeon’s fee might
be negotiable; however, you will be accountable for the fees related to the
operating room, anesthesia, and hospitalization.
This is important information to understand in advance of your surgery. We
value your loyalty, and we will do everything to maximize your care and
results from your surgery.
Should you have further questions, please do not hesitate to discuss them
with me or my office staff.
Sincerely,
Brian K. Howard, M.D.
I have read and understand the above, and agree to this policy
regarding surgery.
Patient signature________________________________
Date_________________________________________
Witness_______________________________________
Dr. Brian K. Howard, M.D., F.A.C.S
Notice of Privacy Practices Written Acknowledgement Form
I, ___________________________________ have been offered the convenience to read Dr. Brian K.
Howard’s Notice of Privacy Practices. There is a laminated copy at the front desk that is available at
all times for any patient to review. If the patient would like a hard copy to take home, please request
such at the front office and one will be provided to you.
Patient Signature ________________________________
Date ___________________________________________
Credit Card HIPPA Release
Dr. Brian K. Howard requires a signed release statement from you, for your credit card that you are
using to pay for your procedure. The reason for this is that we may need to provide information to
THAT card company if there is a dispute with them regarding your transaction.
I understand that NO information will be released unless there is a dispute with your credit card
company.
Patient Signature _________________________________
Date ____________________________________________