TAILOR MADE LOOKS

INSTITUTE OF PLASTIC SURGERY LLC

Plastic and Reconstructive Surgery & Surgery of the Hand

 

PATIENT NAME:
SS#:
REASON FOR VISIT:
AGE:
HOW DID YOU HEAR ABOUT US?
ADDRESS:
CITY, STATE
Zip
PHONE#:
SEX:
DATE OF BIRTH:
MARITAL STATUS:
EMAIL:
EMPLOYER:
WORK PHONE:
CAN WE CONTACT YOU AT WORK IF NEEDED? YesNo
IS THIS A WORK RELATED INJURY? YesNo

IF YES, PLEASE ANSWER THE FOLLOWING QUESTIONS

DATE OF INJURY :
EMPLOYER AT THE TIME OF INJURY:
HAVE YOU NOTIFIED YOUR EMPLOYER OF THIS INJURY:
YESNOCLAIM #
CONTACT AT EMPLOYER :
PHONE:
WORKERS’ COMPENSATION INSURANCE COMPANY :
ADDRESS :
PHONE:
ADJUSTER:
SPOUSE OR PARENT NAME:
SS#:
DOB:
SPOUSE OR PARENT EMPLOYER AND PHONE:
IN CASE OF EMERGENCY, PLEASE NOTIFY :
PR :
INSURANCE INFORMATION: WE MUST HAVE A COPY OF YOUR INSURANCE CARD IN ORDER TO FILL YOUR INSURANCE FOR SERVICES PERFORMED
INSUREDS NAME :
SS# :
INSURANCE COMPANY :
ID# :
PATIENT’S RELATIONSHIP TO INJURED: SELFSPOUSECHILDOTHER
INSURED’S NAME 2:
SS#:
INSURANCE COMPANY :
ID#:
PATIENT’S RELATIONSHIP TO INJURED: SELFSPOUSECHILDOTHER
REFERRING PHYSICIAN :
PH#:

GENERAL FINANCIAL INFORMATION

A PATIENT WHO CARRIES HEALTH INSURANCE MUST PROVIDE US WITH A COPY OF THEIR INSURACE CARD OR THE CHARGES WILL BE THE PATIENT RESPONSIBILITY. I AUTHORIZE PAYMENT OF BENEFITS TO CHICHI BERHANE MD; MBA LLC. THEREBY ACCEPT RESPONSIBILITY OF PAYMENT SHOULD MY INSURANCE COMPANY REFUSE TO PAY. A PHOTOCOPY OF THE AUTHORIZATION AND ASSIGNMENT SHALL BE CONSIDERED AS VALID AS THE ORIGINAL.

*THERE IS A $50.00 CHARGE TO THE PATIENT FOR APPOINTMENTS THAT ARE NOT CANCELLED IN 48 HOURS

SIGNATURE :
DATE:
TIME:

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Appointment





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