New Cosmetic Registration

Name

First Last

Email

Gender

Male
Female
Prefer Not to Answer

Address

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (Home)

Phone (Work)

Phone (Mobile)

Social Security #

Date of Birth

Significant Other

First Last

Marital Status

Single
Married
Divorced
Widowed

Why are you seeing Dr. Portnoy?

Emergency Contact

Name

First Last

Relationship

Phone (Home)

Phone (Work)

Phone (Mobile)

Employment

Are you employed?

Employed Full-Time
Employed Part-Time
Self-employed
Not employed but looking for work
Not employed and not looking for work
Homemaker
Retired
Student
Prefer Not to Answer

What's your occupation?

Name of Employer

Employer Address

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referral

Who referred you to Dr. Portnoy?

Address

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Payment

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Payment*

I agree to the payment policy.

A fee of $200 will be charged before or at the time of service for all cosmetic surgical consultations. This fee will be applied to the cost of your procedure, provided it is performed within 2 months of the consultation. A grace period of 24 hours is permitted if you cancel your cosmetic consultation. Should you fail to cance your appointment within the 24 hour grace period; a $100 fee will be charged to your credit card. We kindly ask that you profied your contact and demographic information, the signed HIPPA privacy notice along with your credit card information (this information is secured and protected under the HIPPA Privacy Act). If you do not posses a credit card, a $200 money order or cash must be presented to the office to secure your appointment. If you fail to provide this information, we regrettably cannot hold an appointment for this service.

Signature, Privacy & Terms

Signature of Patient*

I understand that all medical costs incurred by me are my responsibility; including any charges my insurance fails to pay. I also understand that I am responsible for any collection and/or legal efforts that may be necessary on my account.

Signature of Insured

I authorize payment of medical benefits to the physician for services provided.

Privacy Policy*

I agree to the privacy policy.

In 1996, The US Department of Health and Human Services issued the Health Insurance Portability and Accountability Act (HIPPA). This act essentially regulates how health related information (what has come to be known as "covered transactions") are electronically transmitted. Furthermore, a series of other provisions with respect to patient privacy and security standards have been issued, and were instituted April 14, 2003. This is a summary of the ways in which medical information about you may be used and disclosed, and how you can get access to this information. Dr. Portnoy, his associates, and his entire staff will user your medical information as part of rendering patient care. Your medical information may be used for treatment, payment or health care operations. For exampled, your medical information may be used by the health care professional treating you, by the office insurance coordinator to process your payment for the services rendered, and by administrative personnel reviewing the quality and appropriateness of the care you receive. Your information may also be disclosed pursuant to applicable federal and state law.

The complete notice of Privacy Practices is prepared for your review. We encourage you to read the entire Notice. You are required to acknowledge in writing that you have a read a copy of the Notice. A copy of this document will be maintained in your medical record. The attached Notice is effective as of April 14, 2003.

In selecting this checkbox you acknowledge receipt and acceptance of our privacy practices for protected health information.

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New Cosmetic Registration

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Emergency Contact

Employment

Referral

Payment

Signature, Privacy & Terms

Dr. Portnoy

Temporary Operating Schedule (COVID-19)

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