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Aestheticsnewpatientforms_docx

Anna Rosinska M.D.
3316 Andrews Hwy
Midland, TX 79703
(432) 688-1900
www.AskDrAnna.com

Patient Information and Medical History
NAME_________________________________________________________________________________________

(FIRST) (MIDDLE)

ADDRESS______________________________________________________________________________________

(STREET)
(CITY) (STATE, ZIP)

PHONE # WITH AREA CODE____________________________________________________________________

(WORK) (CELL)

EMPLOYER ______________________________________ OCCUPATION ______________________________
DATE OF BIRTH________________AGE______ SEX: F M SS # __________ -- ______--_________
DRIVER’S LICENCE # _______________________________STATE _________________ EXP ______________
EMERGENCY CONTACT ______________________________________RELATIONSHIP__________________
ADDRESS ______________________________________________________________________________________

(STREET)

PHONE # WITH AREA CODE____________________________________________________________________

WOULD YOU LIKE TO RECEIVE OUR MONTHLY EMAIL? YES NO
EMAIL ____________________________________________________
HOW DID YOU FIND OUT ABOUT US? _____________________________________________

************************************************************************
Allergies of any kind (food, meds)___________________________________________________________________
Current/recent medications:_______________________________________________________________________

Height: ______ft ________in Weight: ________________ Desired Weight: _________________

Please mark if you have any of the medical conditions:
Diabetes High Blood Pressure Heart Problems Mitral Valve Prolapse Palpitations
Bleeding Problems (low platelets count, hemophilia, blood dyscrasia)
Taking anti-inflammatory meds (Aspirin, Motrin, Aleve, Naprosyn, Mobic) or Blood Thinners?
History of recurrent Cold Sores / Fever Blisters / Herpes
Pregnant or planning to get pregnant in the nearest future? Yes No
Any other medical conditions? If yes, please explain _________________________________________________
I ATTEST THE ABOVE INFORMATION TO BE TRUE, KNOWING MY PROVIDER RELIES ON THIS INFORMATION
TO PROVIDE SAFE AND EFFECTIVE TREATMENT.

___________________________________________________ ____________________________
SIGNATURE
Anna Rosinska M.D.
3316 Andrews Hwy
Midland, TX 79703
(432) 688-1900
www.AskDrAnna.com

Due to the popularity of our services, we have found it necessary to implement the following policy regarding the scheduling of appointments. Once scheduled all appointments require a minimum of 24 hour notice for cancellation. Failure to follow this policy will result in the following: Missing 1 appointment without notice: $ 25.00 Charge. Missing 2 appointments without notice: $ 50.00 Charge. Missing 3 appointments without notice: $ 75.00 Charge. No future appointments will be honored until the above fees are paid. For Complimentary and Gift Certificate Appointments: Missing ANY complimentary appointment without a 24-hour notice will result in Complete Forfeiture of the appointment. Gift Certificates are subject to the same charges as regular appointments. I have read and fully understand this policy and agree to follow the terms within. Signature ___________________________Date ________ A copy of this agreement will be provided to you upon request. HIPAA POLICIES AND PROCEDURES

We are permitted to disclosure protected health information (PHI) to those involved
in the treatment of your medical conditions (ER physicians, hospitals, ect). We also may
disclose PHI without your written authorization.
We are not allowed to release PHI to anyone without written consent. If the patient
is a minor (under 18 years of age) we can only release PHI to parent or legal guardian, If
the patient is an adult but incapacitated or unable to sign for his/her medical records we are
allowed to disclose PHI to the person that has power of attorney after submitting a copy of
the legal documentation.
We are not permitted to disclose PHI received from another physician to a patient.
Information has to be obtained directly from this physician.
PRINT NAME: _______________________________
SIGNATURE: ________________________________ DATE: ______________________

Source: http://askdranna.com/pdf/AestheticsNewPatientForms.pdf

Part 1/section

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