Intake form - Delozier Cosmetic Surgery Center

Date

Patient Full Name

Patient Preferred Name (if different than above)

Patient Address

City

State

Zip Code

Phone

Home

Cell

Work

Sex

Male Female

Birth Date

Age

Social Security #

Place of Employment

Occupation

Marital Status

Spouse’s Name (if applicable)

E-Mail Address

May we contact you via e-mail?

Yes No

What would you like to discuss with Dr. DeLozier today?

When would be the best time for you to undergo your procedure?

Is there someone we may thank for your referral?

Medical History

Patient Full Name

Date of Birth

Primary Care Provider

Phone Number

Fax Number

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

Medication allergies with associated reactions

Do you have a latex allergy?

Yes No

Do you have a tape allergy?

Yes No

Height

Weight

Do you smoke?

Yes No

How much?

List any nicotine products used (ie: tobacco, vaping, e-cigarettes, patches, gum)

Do you drink alcohol?

Yes No

How much?

What is your daily pain score? (0=no pain, 10=severe pain)

Medications

Do you take a blood thinner?

Yes No

If so, which one?

For what condition?

Who prescribes and manages your blood thinner?

Phone Number

Fax Number

Please list your current medications (include any over-the-counter medications, vitamins, etc.)

Please list all surgeries that you have ever had:

Patient Disclosures

Patient Full Name

Date of Birth

May we leave a detailed message on your voicemail?

Yes No

May we send a text message?

Yes No

Emergency contact

Phone

May we discuss/disclose your account of medical information with members of your family or other persons known to you? If yes, you must list their name(s) below. We will only discuss information with those listed below:

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

By signing below, I authorize the discussion of my plan of care with the individuals listed above.

Patient signature

*by typing my name into this box I understand this serves as my signature and I authorize the discuss of my plan of care with the individuals listed above.

Patient Agreement

Limitation of Practice: Patient understands that the practice of Joseph B. DeLozier, III, MD, PLLCis limited to Plastic and Reconstructive Surgery.

Patient Consent: Patient hereby gives consent, if needed, for drawing blood samples for diagnosis or in case of accidental puncture or exposure to medical personnel during my course at meant either in the offices or the hospital. These tests may include AIDS testing.

Tennessee Controlled Substance Monitoring Database (CSMD): Joseph B. DeLozier, III, MD,PLLC abides by the rules and regulations set forth by the State of Tennessee regarding the CSMD as required by law. Patient herby gives consent for the practice to access any and all records held by the Department of Health relating to Schedule II-V controlled substances dispensed to the patient.

Privacy Policy

All patients have a right to review our Notice of Privacy Practices. Any employee of the practice can provide you a copy of the Notice of Privacy Practices. If you would like to restrict access or request modifications be made to your Personal Health Information, please request the required form from a member of our staff.

Collection Policy

Assignment and Release: The service(s) you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. All cosmetic fees are due PRIOR to surgery or at the time cosmetic laser and skin care services are rendered. The patient authorizes the release of information necessary to process insurance claims. The patient authorizes photographs to be restricted for medical, education, or insurance purposes and information released to other practitioners in good faith effort for my medical care.

Maximum 30-Day Period for Unpaid Balances

In the alternative, the patient must make acceptable payment arrangements by contacting the Billing Department at Joseph B. DeLozier, III, MD, PLLC. Balances may be paid via cash, check, Visa, or MasterCard.

Unpaid Balances

If for any reason the patient cannot make scheduled payments, the patient must immediately contact the Office at Joseph B. DeLozier, III, MD, PLLC to make acceptable arrangements. Joseph B. DeLozier, III, MD, PLLC reserves the right to refer all unpaid accounts to collection agencies. Any fees associated with collection, including collection agency contingency fees and court costs, will bead ded to the patient’s account balance. After accounts are place with collection agencies, all patient visits and procedures will be on a cash only basis.

Service Charge

Joseph B. DeLozier, III, MD, PLLC reserves the right to assess a service charge, not to exceed $20 per month, to a patient account for any unpaid balance over 30 days. No service charges will be assessed to patient account where the patient has made payment arrangements with the Billing Department and payments are being made as agreed.

All questions concerning these policies should be directed toward the administrator.

Patient signature

*by typing my name into this box I understand this serves as my signature.

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