PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ PHONE: FAX:

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1 PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ PHONE: FAX: Patient Information as of (todays date). Please print legibly and indicate an answer to all questions. Patient s Name Address Last First Middle Street & Apt # City State Zip Home #: Cell #: Other #: Birthdate SS# - - Gender: Female Male Marital Status Single Married to: Other: Patient s Employer Occupation Work #: Ext: Is it okay to call you at work? Yes No Address City State Zip Emergency Contact Relationship to Patient Home #: Cell #: Other #: Medications and Allergies Pharmacy: Phone: Are you currently taking aspirin? No If Yes : 81 mg (baby) 325 mg Usage non-steroidal anti-inflammatory drugs (ex. Motrin, Aleve, Tylenol): Daily Occasionally Weekly Rarely Never Coumadin use: No

2 Are you currently taking medications, vitamins or supplements? No If you answered Yes, please list below: Medication Dosage Supplements Dosage Are you allergic to latex? No Are you allergic to nickel? No Not Sure Do you have any allergies? No If you answered Yes, please list your allergies:. Medical History This Medical History Form is part of a Confidential Medical Record and will not be released unless you have authorized us to do so. The information contained in this form will be used by Dr. Glatt in decisions regarding your medical care and treatment. Please answer all questions to the best of your knowledge. Name: DOB: _ Today s Date: Height: Weight: Date of Last Physical Exam: Primary Physician: Phone: Address:

3 Please check any conditions below that you have or had in the past (indicate date(s) of occurrence). Blood Clots in your legs Goiter/Thyroid Disease _ Blood Clots in your lungs Hyperthyroidism _ Diabetes _ Hypothyroidism _ Tuberculosis Pneumonia _ Arthritis _ Bronchitis _ Hypertension Bleeding Tendency _ CAD (Coronary Artery Disease) Migraine Headaches Hypercholesterol Epilepsy _ Heart Attack Stroke _ Congenital Heart Disease HIV+ _ Rheumatic Heart Disease Cold Sores/Fever Blisters _ Hepatitis Herpes Genital _ Stomach Ulcers Cancer _ Colitis Kidney Disease _ Please list other not on list: No medical issues. Do you have any children? No If yes, what are their ages: Have you ever smoked cigarettes? No/Never If yes, currently, how many per day? For how long? If you previously smoked and have quit, when did you quit? Alcohol usage: No If yes, what type and how much? Do you use/have you used recreational drugs? No If yes, what and how often? Have you ever had treatment by a counselor, psychiatrist or psychologist? No If yes, when and for what condition? Were you prescribed any medication as part of this treatment? No If yes, list medication(s) prescribed: Do you have any implants/artificial limbs/prostheses? If yes, where?_

4 Do you have a pacemaker or Automatic Implantable Cardioverter Defibrillator(AICD)? No List name and date of ANY surgery you have had:. Have you ever had an adverse reaction to anesthesia/surgery? No If yes, explain:. Women Only Hormone Replacement Therapy? Never Taken Current Usage Taken in Past Oral Contraceptives? Current Use Past Usage Never Used Date of most recent mammogram? Are you still having regular monthly menstrual periods? Have you ever had a discharge from the nipple of your breast? No - When?_ Do you regularly have PAP smears? No How many pregnancies? - If yes, date of last test? Cesarean deliveries? What are the ages of your children? Are you planning on having more children? No Sign Below I certify that the medical information I have provided is accurate and complete to the best of my knowledge. Signature Date

5 Office Policies Patient Name: Privacy Policy The privacy of your medical information is of the utmost importance to our practice. We adhere to all laws governing protection of your medical information as outlined in the Health Insurance Portability and Accountability Act of You may obtain a copy of our Privacy Policy at the time of your visit to our office. It may be necessary to release your protected health information to banks, insurance companies, financing companies and/or credit card entities to facilitate your payment. By initialing below I consent to allow Premier Plastic Surgery Center of New Jersey to use and disclose this information to the above named entities when such information is requested to process a payment. Initial: Financial Policy Summary Office visits are payable on the day of service. For your convenience, we accept American Express, Discover, MasterCard, Visa, checks and cash. Any returned check will incur a bank fee charge. Unpaid accounts are subject to collection fees up to 50% of the outstanding balance. Credit Card refunds incur a 3% service charge. Dr. Glatt participates in Medicare and Atlantic Health System PPO. If you have insurance other than the above you will be utilizing your out of network benefits. As a courtesy we will submit insurance claims on your behalf; however any balance remains your responsibility. A copy of our complete Financial Policy is available at our office and will be provided to you upon request. Communication May we send mail to your home address? Yes No May we contact you via ? Yes No May we contact you via text message? Yes No Initial : Initial: My signature below certifies that I have read, understand and agree to the above policies. Signature: Date:

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