PATIENT REGISTRATION

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Step 1 of 11

Plastic/Cosmetic Surgery Questionnaire

Patient Full Name*

First Last

Today's Date

MM slash DD slash YYYY

A. Please indicate the following services, products, procedures and/or health issues of interest to you. Dr. Diamantis will be glad to review these particular interests with you..

1. Facial Plastic Surgery

(Please check all the boxes that apply).

Eyelid surgery- Blepharoplasty will help rejuvenate tired, puffy/sagging eyes

Cosmetic Nose Surgery- Rhinoplasty, to help shape your nose into a more elegant shape

Facial Implants- to permanently enhance facial disharmony with cheek/chin implants

Brow Lift- to permanently soften forehead wrinkles and lift eyebrow position

WeekendLIFT™ - an innovative procedure to rejuvenate the face with minimal surgery

Face and Neck lift- Rhytidectomy is traditional surgery to rejuvenate the face and neck

Ear Surgery- Otoplasty is designed to improve prominent large ears

Ear Lobe Repair- Repair damaged or split ear lobe.

Double Chin Correction- several simple options are available (i.e. submental liposculpture)

Scar Revision-Several plastic techniques to improve large unsightly scars

2. Non-Surgical Facial Rejuvenation

(Please check all the boxes that apply).

Wrinkle Correction w/muscle relaxation- Neuromodulators

Laugh & Marionette Wrinkle Correction- HA and Biologic Fillers

Mid Face Lift- Stem Cell & Biologic Filler is a long-lasting option to rejuvenate age related volume loss

Double Chin Correction- Submental Liposuction treatment to shrink unwanted fat

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

Hands - Radiesse provides long-lasting improvement for volume loss in the hands

3. 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- HA and Biologic fillers to temporarily improve lip volume and shape

4. 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 & Bellafill)

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

5. Miscellaneous Cosmetic Procedures

(Please check all the boxes that apply).

Hyperhidrosis (excessive sweating of armpits)- a common social concern treated with neurotoxin

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

6. Body Cosmetic Surgery Procedures

(Please check all the boxes that apply).

Vaser® Liposculpture of trunk and legs - Several innovative techniques are available

Gynecomastia /Male Breast Surgey- Several procedures to remove male breast tissue

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

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

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

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

C. 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)

Another person not listed above (full name)

Internet search:

Which seminar/lecture?

Patient Registration Form

Patient Full Name*

First Last

Phone*

Home

May we periodically send you SMS text messages and/or emails about appointments, products, services and promotions?*

Yes

Address*

Street Address City State ZIP / Postal Code

Gender*

Age*

Birthdate*

MM slash DD slash YYYY

Marital Status*

Employers Name

Occupation

Whom can we thank for referring you?

In case of emergency whom should we notify?

Their phone

Primary Medical Insurance

Person responsible for Account

Relation to Patient

Birthdate

MM slash DD slash YYYY

S. S. #

Address (if different to patient’s)

Street Address City State ZIP / Postal Code

Phone

Person Responsible Employed By

Business Phone

Insurance Company Name:

Group #

Subscriber #

Medical Questionnaire

Patient Full Name*

First Last

Address*

Street Address

Phone

Height*

Age*

Weight*

Family Doctor

Family Doctor`s Phone

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

2. Pre-operative Medical History:

A. Do you have or have you ever had. Check all that apply:*

Diabetes

Heart Disease

Heart Attack (MI)

Ankle Swelling

Shortness of Breath

Kidney Disease

Rheumatic Fever

Liver Disease

Anemia

Abnormal Bleeding

Recent cold, flu, or Covid

Glaucoma

Mitral Valve Prolapse

Heart Murmur

Thyroid Disease

Sleep Apnea

Snoring

Scarlet Fever

Epilepsy/Seizures

Lung Disease

COPD

Tuberculosis

Asthma

Venereal Disease

High Blood Pressure

GI Reflux

Ulcers

Pregnancy

H.I.V/ A.I.D.S

Hepatitis A

Hepatitis B

Hepatitis C

TMJ pain/clicking

Joint Replacement

Bleeding Disorder

Infection/MRSA

Eczema/ Psoriasis

Autoimmune disease

None of above

3. Family History: Please answer all questions by checking all that apply:

Has any family member ever had:*

Bleeding Disorder

Deep Vein Thrombosis (DVT)

Pulmonary Emboli

Cancer

Diabetes

High Blood Pressure

Vitiligo

Malignant Hyperthermia

Autoimmune Disease

Multiple Sclerosis

None of above

If you answer ‘yes’ to any above questions? Please elaborate:

Are you under a physician’s care?*

Reason*

List previous Hospitalizations / Operations: Elective or Non-Elective

Have you had any fillers/toxins: and if so, when was your last treatment?*

Are you currently pregnant?*

Do you have an allergy to Latex?*

Do you have any allergies to medications?*

If yes, please provide us with the name of the medication and explain the signs and symptoms:

Current Medication List (include all vitamins & herbal supplements)

Medication

Dose

Frequency

Reason for Taking

Have you ever had radiation therapy or chemotherapy?*

Explain

Have you ever had general anesthesia? (i.e. sleep)*

Complications

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

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

MM slash DD slash YYYY

History of Vitiligo?*

Do you smoke (please include vaping)?*

How many years?

How often (vape)?

Do you drink alcohol?*

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/anxiety?*

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

If yes, explain:*

Have you ever had complications from previous plastic surgery procedures?*

Complications

List and date all the cosmetic/plastic surgery procedures you have had:

Click on + icon to add more information

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.

Have you ever had diarrhea/ colitis caused by antibiotic therapy?

Are you on hormone therapy?

Reason for hormone therapy

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.*

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

Patient Full Name*

First Last

Patient's Signature*

Today's Date*

MM slash DD slash YYYY

OFFICE USE ONLY: Doctor's Signature

OFFICE USE ONLY: Date

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.

Patient's Signature*

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

Print Name*

Today's Date*

MM slash DD slash YYYY

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 15, 2010 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

REQUESTING A COPY OF OUR NOTICE

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of the Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

TREATMENT: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
PAYMENT: We may use and disclose your health information to obtain payment for services we provide you.
HEALTHCARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

YOUR AUTHORIZATION:

In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it is in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

NOTICE OF PRIVACY PRACTICES (continued)

TO YOUR FAMILY AND FRIENDS: We must disclose your health information to you, as described in the patient rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment of your healthcare, but only if you agree that we may do so.

PERSONS INVOLVED IN CARE: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your locating, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

MARKETING HEALTH-RELATED SERVICES: We will not use your health information for marketing communications without your written authorization.

REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law.

ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonably believe that you are possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

NATIONAL SECURITY: We may disclose to military authorities the health information of Armed Forces Personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

PATIENT RIGHTS ACCESS: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request copies, we will charge you $0.50 for each page, $20.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

NOTICE OF PRIVACY PRACTICES (continued)

DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities for the last 6 years, but not before April 15, 2010. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

RESTRICTION: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

ALTERNATE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request.

AMENDMENT: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under any circumstance.

ELECTRONIC NOTICE: If you receive this Notice on our website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS: If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Vas Diamantis
Telephone: 216-227-3333
Fax: 440-845-4556
Email: dr.diamantis@clevelandcosmeticsurgery.com
Address: 14700 Detroit Avenue, Lakewood, Ohio 44107

Patient Full Name*

First Last

Patient's Signature*

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

Today's Date*

MM slash DD slash YYYY

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:

Dr. Nicholas C. Diamantis

Doctor’s Name

14700 Detroit Avenue

Address

Lakewood, Ohio, 44107

Requesting Information:

Patient's Name*

First Last

Patient's I.D. Number

Patient's Birthday*

MM slash DD slash YYYY

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.

Witness’ Signature

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

Today's Date

MM slash DD slash YYYY

Hidden

Certification of Witness Signature

I acknowledge that my name below certifies my electronic signature.

Hidden

Witness Name

Hidden

Date

MM slash DD slash YYYY

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.

Patient's Name*

First Last

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*

MM slash DD slash YYYY

FOR OFFICE USE ONLY

We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because:

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):

Hidden

Employee Signature

Hidden

Date

MM slash DD slash YYYY

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):

By filling out and submitting this form, you are agreeing to our privacy policy.

Agree*

Agree

I am granting permission for your company to contact me by phone, email, and SMS for service, sales and/or marketing purposes.