Patient Registration Form

Patient Full Name*

First Last

Email Address*

Phone Number*

Today's Date

Please answer the following questions on a scale between 1 -5 by checking the range you feel is most appropriate.

1. Facial Plastic Surgery

(Please check all the boxes that apply).

2. Body Cosmetic Surgery Procedures

(Please check all the boxes that apply).

Liposculpture of trunk, bra line, legs and arms-several innovative techniques are available

Brazilian Butt Lift- a new technique to enhance your backside and buttock region

Gynecomastia /Male Breast Surgery-several procedures to remove male breast tissue

Non-invasive body contouring- Zerona®, Cool Sculpting® and Smart Lipo®

3. Non-Surgical Facial Rejuvenation

(Please check all the boxes that apply).

Wrinkle Correction w/muscle relaxation- Botox®, Dysport®

Laugh & Marionette Wrinkle Correction- Juvederm®, Restylane®, Radiasse®, Sculptura® …etc.

Mid Face Lift- Voluma® is a long-lasting option to rejuvenate age related volume loss

Double Chin Correction- Kybella® is an FDA approved treatment to shrink unwanted fat

Fat/ Stem Cell Transfer- your fat/ stem cells are prepared and used as a permanent filler

4. Lip Augmentation

(Please check all the boxes that apply).

Lip Lift- a permanent procedure to enhance the volume and shape of the lips & mouth

Lip Implants- a soft naturally shaped implant to permanently enhance the lips

Fat/ Stem Cell Transfer- native fat is transferred to the lips to permanently improve lip size

Lip Enhancement- Juvederm®, Voluma®, and Restylane® temporarily improve lip volume and shape

5. Skin Rejuvenation and Health

(Please check all the boxes that apply).

Acne Treatment- several medical options are available (i.e. Clenziderm®, Photo Facials)

Facial Wrinkles & Skin Tightening- Photo Facials, Pixel Perfect® Laser & Chemical Peels

Skin Tone and Texture- Harmony 360®, Pixel Perfect®, & Sclerotherapy for vein treatment

Dark Circles Under Eyes- permanent treatment with proprietary phenol peel to lighten & smooth

Acne Scar/ Pox Scar Correction- several medical options are available (i.e. Dermabrasion)

Skin Care Program- a medically prescribed and monitored skin care regimen (i.e. Obagi®, PCA®)

6. Miscellaneous Cosmetic Procedures

(Please check all the boxes that apply).

Hyperhidrosis (excessive sweating)- a common social concern treated with Botox®

Eyelash Enhancement/Latisse® - is formulated to thicken, darken & elongate eyelashes

Hair Removal- permanent hair removal of the face, bikini, under arms, back & legs with Laser Therapy

Spider Vein Therapy- removal of unsightly red spots, telangiectasia’s with laser &/or sclerotherapy

Thinning Hair and Hair Loss- medical hair restoration is a permanent solution

Please answer the following questions on a scale between 1 -5 by checking the range you feel is most appropriate.

When looking in the mirror, I believe I look younger, the same as, or older than my true age.

When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about my facial appearance.

How did you hear of our practice? A referral from a previous patient is the highest honor you can bestow on us. Please provide their full surname & email so we may formally thank them.

Healthcare provider (full name)

Previous patient of Cleveland Cosmetic Surgery (full name)

A friend or family member (full name)

Internet search:

Which seminar/lecture?

Another person not listed above (full name)

Page 1

Patient Full Name*

First Last

Medical Questionnaire

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Age*

Height*

Weight*

Family Doctor

Family Doctor's Phone Number

What brings you to our office today; How can we help you?*

Page 2

Name*

First Last

Current Medication List (include all vitamins & herbal supplements)

Medication

Dose

Frequency

Reason for Taking

Have you ever had local anesthesia? (i.e. Novocaine)*

Complications

Do you wear contact lenses?*

Have you ever used Accutane?*

Dates you used Accutane*

History of Bells Palsy?*

History of dry eyes?*

Last eye exam

History of Vitiligo?*

Do you Smoke/Vape?*

How many per day?

How many years?

Do you use any “street” drugs:*

Cocaine, Heroin, Ecstasy or Marijuana (specify amount per day)

Have you had any past treatment for chemical dependency?*

Have/are you being treated for an eating disorder?*

With previous surgeries, have you experienced?

Abnormal bleeding?

Infection?

Delayed Healing?

Other complications?

Are you currently or have ever been treated for depression?*

Are you currently/have ever been treated for a psychological disorder?*

If yes, explain:*

Please describe below any other pertinent medical, psychological, or physical condition not mentioned above: Your thoroughness will assist Dr. Diamantis to develop the ideal treatment plan for you.

I understand the importance of a truthful and accurate health history to assist Dr. Diamantis in providing the safest and best care possible.*

I have answered the above questions truthfully and to the best of my knowledge.

Name*

First Last

Patient's Signature*

Today's Date*

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Doctor's Signature

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Date

Page 4

Office Financial Policy

To give our patients the best care possible, it is important to help us maintain our records and keep our accounts current.

Fees and Deposits.

For elective cosmetic surgical procedures, we require a deposit of one-half (½) of the total fees to be paid at the time you schedule your surgery. The balance of the fees must be paid in full at the time of your pre-surgical consultation, which is scheduled two weeks prior to your surgery.

Insurance.

Cleveland Cosmetic Surgery does not accept insurance of any type as payment for surgical procedures. You are personally responsible for payment for your elective cosmetic surgery.

Payment Options.

For your convenience, we gladly accept MasterCard, Visa, American Express and Discover for payment. If you choose to pay by credit card, there will be a 3.5% convenience fee added to the amount of your charge. The convenience fee is not refundable under any circumstances. We will only accept personal checks up to 21 days prior to your scheduled surgery date. There will be a $50.00 fee for all checks returned to us. All delinquent accounts will be referred to collections and you will be responsible for additional fees.

Cleveland Cosmetic Surgery also has relationships with third party credit lenders such as Care Credit to assist you with payment options. Please ask for details.

Appointment and Cancellation Policy.

Your appointment time is reserved exclusively for you and we have scheduled medical staff to be available for your appointment time and location. We know your time is valuable, so please remember ours is too. If you must cancel a surgery date with less than 21 days notice, you will lose 50% of your proposed treatment plan and will also be charged an additional $500.00 fee for the cancelled anesthesia team. These cancellation fees are allocated for administrative, facility and medical purposes. Additionally, there will be no cash refunds for the balance of the fee, however, any credit balance may be used for future surgical procedures or purchase of products

Certification of Signature*

I acknowledge that I have read and understand the Financial Policy and agree to be bound by its terms. questions truthfully and to the best of my knowledge.

Patient´s Signature*

Please sign your name either using your fingers for touch devices or using your mouse.

Print Name*

Today's Date*

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Doctor´s Signature

Please sign your name either using your fingers for touch devices or using your mouse.

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Print Name

Hidden

Date

Page 5

Name*

First Last

Social Security Number

Sex*

Birth Date*

Maritial Status*

Employer's Name

Occupation

In case of emergency who should be notified?*

Emergency Contact Phone Number*

Primary Medical Insurance

Person responsible for Account*

Birth Date of Person Responsible for Account*

Social Security Number

Address (if different from patient)

Street Address Address Line 2 City State ZIP Code

Person Responsible Employed By

Business Phone

Insurance Company Name

Group #

Subscriber #

If you like a copy of privacy practices we will Provide once they are in the office.

Page 6

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I hereby request and authorize the release of all information, without limitations regarding any physical and mental condition, as revealed by your observation or treatment, past, present or future.

This includes medical, surgical and dental history, x-ray findings, diagnosis, prognosis and access to all hospital records and photocopies of the same.

I request that you release the above information to:

Doctor's Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Requesting Information:

Name*

First Last

Patient's Birthday

Patient's I.D. Number

Certification of Signature

I acknowledge that my name below certifies my electronic signature.

Patient's Signature

Please sign your name either using your fingers for touch devices or using your mouse.

Name

Today's Date

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Certification of Witness Signature

I acknowledge that my name below certifies my electronic signature.

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Witness Name

Hidden

Date

Page 7

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY RIGHTS

Cleveland Cosmetic Surgery is required to provide you with a copy of the Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this Form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgment if you wish.

Name*

First Last

Additional information requested:

At which of the following number(s) do we have permission to contact or leave messages for you regarding your treatment, medication or financial/insurance information?

Mobile*

Home Phone

Work Phone

Other than your insurance carrier, who may we speak with about your healthcare information?

Spouse

Parent

Child

Other

Phone Number

I acknowledge that I have received a copy of this office’s Notice of Privacy Practices and I have had an opportunity to review it.*

I acknowledge that my name below certifies my electronic signature.

Signature*

Please sign your name either using your fingers for touch devices or using your mouse.

Name*

First Last

Today's Date*

FOR OFFICE USE ONLY

Hidden

Date

Hidden

Annotations

The patient refused to sign.

Due to an emergency situation it was not possible to obtain an acknowledgment.

We are not able to communicate with the patient.

Other (Please provide specific details):

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Employee Signature

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Date

Page 8

PATIENT REGISTRATION