Mansfield*Cosmetic*Surgery*Center* *New*Patient*Welcome*Packet* 817>477>9000* *
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- Jean Fletcher
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1 DearPatient, WelcometoMansfieldCosmeticSurgeryCenter,thecosmeticsurgerypracticeofDr. MichaelL.Thornton,afellowship>trainedcosmeticsurgeonandDiplomateoftheAmerican BoardofCosmeticSurgery. ThisNew$Patient$Welcome$Packetwillspecificallyprovidevaluableinformationaboutthe variouscosmeticsurgeryservicesofferedatmansfieldcosmeticsurgerycenter.itwillalso containinformationaboutourcosmeticsurgicalpractice,profileofdr.michaelthornton, ourofficehoursandlocation,theappointmentandconsultationprocess,aswellasprovide informationaboutyourfinancialoptionstoobtainaffordablecosmeticsurgery. Toexpediteyouroverallconsultationprocess,pleasetaketimetocompletetheattached Medical$HistoryformbeforeyourvisitwithDr.MichaelThorntonandbringtoyour consultation.ifyoudesire,youmayeither orfaxthecompletedformpriortoyour officevisit.asitwillexpediteyouroverallconsultationprocess Feelfreetocontactourofficetodiscussanyconcernsyoumayhaveaboutyourcosmetic surgeryconsultation.itisveryimportantthatyourquestionsareansweredbeforeyou undergoanysurgicalornon>surgicalprocedure. Sincerely, Dr.MichaelL.Thornton&Staff MansfieldCosmeticSurgeryCenter Office Fax3 MansfieldCosmeticSurgeryCenter NewPatientWelcomePacket 817>477>9000
2 About Us MansfieldCosmeticSurgeryCenterwasestablishedin2008underthesurgicaldirectorship ofdr.michaell.thornton,afellowship>trainedcosmeticsurgeonanddiplomateofthe AmericanBoardofCosmeticSurgery.OurofficeislocatedinMansfield,Texas,andweserve clientsfrommansfield,arlington,fortworth,dallas,andthesurroundingcitiesofnorth CentralTexas. Our3500sq.ft.cosmeticsurgerycenterandmedicalspaisconstructedonthegorgeous Mediterranean>styleexecutiveofficepropertyoftheTuscanonWalnutCreek,locatedin Mansfield.OursurgicalofficefeaturesalargeandspaciousfoyeraccentedinTuscan grandeur,threeprivateexaminationrooms,ourmedicalspafacility,andourprivate operatingroom. Duringyourcomplimentaryconsultation,Dr.Thorntonwillpersonallyevaluateyour health,conductaprivatephysicalexamandexplainwhichcosmeticsurgicalprocedures aremostappropriateforyouasitrelatestoyouruniqueandpersonalcircumstance.your privatecosmeticsurgeryconsultationisbookedforapproximatelyonehouranddr. Thorntonwillspendasmuchtimenecessarytoestablishacomprehensiveandthorough physician>patientrelationshipwithyou.thislevelofpersonalattentionfromdr.thornton iswhatdefinesoursurgicalpractice.althoughwellqualified,wechoosenottousea patientcoordinator,nursepractitioner,orphysicianassistant(pa)toperformyour consultation.inaddition,dr.thorntonwillpersonallyseeyouduringeverypost>operative visitfollowingyoursurgerytopersonallyaidinyourhealingprocessandprovide physician>levelcare. CosmeticsurgeryproceduresrequiringgeneralanesthesiaareperformedatBaylor$ Surgicare$at$Mansfield,anout>patientAAAHCcertifiedsurgicalfacility,locatedjustafew milesfromouroffice.however,cosmeticsurgeryproceduresrequiringminimalsedation, maybeperformedinourownprivateoperatingroom.furthermore,dr.thorntonhasfull cosmeticsurgeryandgeneralsurgeryprivilegesatthemedicalcenterofarlingtonto manageanypostsurgicaldifficulties. MansfieldCosmeticSurgeryCenter NewPatientWelcomePacket 817>477>9000
3 About Dr. Michael L. Thornton GrowingupinTexas,Dr.Thorntonreceivedhispremedical Bachelor sdegreefrombayloruniversityandreceivedhis MedicaldegreefromtheUNTHealthScienceCenterinFort Worth.Hecompletedacomprehensivefive>yeargeneral surgeryresidencythroughmichiganstateuniversity affiliatedhospitalsatmountclemensregionalmedical CenterinMountClemens,Michiganandcompletedan additionalone>yearfellowshipinsurgicalcriticalcareand TraumaSurgeryattheinternationallyrecognizedRAdams CowleyShockTraumaCenterattheUniversityofMaryland MedicalCenterinBaltimore,whereheacquiredextensive knowledgeinthemanagementandreconstructionof complextraumaticinjuries. Followingacreativepassion,Dr.Thorntonfurtheredhis surgicalexpertisebycompletinganadditional,12>monthadvancedfellowshipincosmetic Surgery,accreditedandrecognizedbythe3AmericanAcademyofCosmeticSurgery,where hegainedconcentratedknowledgeinallmajorareasofcosmeticsurgeryincludingfacial plasticsurgery,rhinoplasty,cosmeticbreastsurgery,liposuction,bodycontouringsurgery, non>surgicalaesthetics,skincarerejuvenation,andlasermedicine. Dr.ThorntonisaDiplomateofthe3AmericanBoardofCosmeticSurgery(ABCS),whichis theonlywrittenandoralcertifyingboardthatexclusivelytestsknowledgeandexperience inartofcosmeticsurgery,andheiscurrentlyservinga3>yeartermasanoralboard examinerfortheabcs.inaddition,heisdual>boardcertifiedbytheamericanosteopathic BoardofSurgeryinbothGeneralSurgeryandSurgicalCriticalCare/TraumaSurgery. BecauseofDr.Thornton sthreeboard>certificationsandsurgicaldedication,hehasbeen bestowedtwoesteemedhonorsasfellow$in$the$american$college$of$osteopathic$surgeons$ (FACOS)andasFellow$in$the$American$Academy$of$Cosmetic$Surgery$(FAACS).Inaddition,he hasover14>yearsofcombinedsurgicaltrainingandoperativeexperienceandhasbeen named TopDoc infortworth,texasmagazine,inthespecialtyofcosmeticsurgery. Dr.Thorntonisatalentedandcompassionatecosmeticsurgeonandhisphilosophyisfor youtoachieveanaturalandimperceptibleresultthatfocusesonyourspecificgoals,while carefullyattemptingtominimizeanyscars.hebelievesyourcosmeticsurgeryisonly successfulwhenyouarehappyandpleased! MansfieldCosmeticSurgeryCenter NewPatientWelcomePacket 817>477>9000
4 Affordable Cosmetic Surgery MansfieldCosmeticSurgeryCenteroffersoptionsforaffordablecosmeticsurgeryby acceptingmajorcardcardsincluding,mastercard,visa,andamericanexpress. Inaddition,wearepleasedtoofferCare$Credit,oneofthenation sleadingcosmeticsurgery paymentprogramsmakingiteasytoaffordcosmeticsurgeryproceduresyoudesire.with Care$Credityoumayfinanceyourcosmeticsurgeryprocedureswithoutupfrontcosts,no annualfees,andnopre>paymentpenalties.so,youcanscheduleyourproceduretodayand convenientlypayovertimewithlow,monthlypayments.seebelowformoredetailsorto applyforanon>lineapplicationofyourchoosing. Contact Us / Office Location MansfieldCosmeticSurgeryCenterislocatedintheheartoffMansfield,TexasonNorth WalnutCreekDrive,justwestofHwy287pasttheWalmartandUnitedMethodistChurch. Tobetterassist,youmayclickthe ContactUs tabonourwebsiteandfollowdirections usinggooglemaps.pleasecontactourofficeifyouhaveanyquestionslocatingouroffice. MansfieldCosmeticSurgeryCenter 550N.WalnutCreekDrive,Ste120 Mansfield,TX76063 OfficeHours: MondaythruFriday 9am 5pm ConsultationswithDr.Thorntononly Monday,Wednesday,andFriday MansfieldCosmeticSurgeryCenter NewPatientWelcomePacket 817>477>9000
5 Cosmetic Surgery Procedures FACIAL3COSMETIC3SURGERY3 EyelidLiftSurgery Blepharoplasty FaceLift NeckLift MiniFaceLift BrowLift FacialFatTransfer&Grafting TornEarlobeRepair Keloids SurgisilPermalipImplant Chinimplant BODY3CONTOURING3SURGERY3 Abdominoplasty MiniTummyTuck MommyMakeOver Liposuction LaserLiposuction Brachioplasty ArmLift BrazilianButtLift HandRejuvenation AfterWeightLoss PostBariatricSurgery AbdominalHerniaRepair Sclerotherapy SpiderVeinInjection BREAST3COSMETIC3SURGERY3 BreastAugmentation BreastLift BreastReduction BreastRevisionSurgery Gynecomastia MaleBreastSurgery MEDICAL3SPA3 3AESTHETIC3PROCEDURES3 CO2LaserSkinResurfacing Botox Juvederm Radiesse Latisse IPL Photofacial Microdermabrasion ChemicalPeels Facials Waxing PermanentMakeup Obagi SkinCeuticals MansfieldCosmeticSurgeryCenter NewPatientWelcomePacket 817>477>9000
6 Mansfield Cosmetic Surgery Center 550 N. Walnut Creek Drive, Ste 120 Mansfield, TX New Patient Medical History - Cosmetic Surgery Full Name Date Address City State Zip address SSN# Home phone Business phone/cell Emergency Contact: Name Phone Date of Birth Age Male Female Marital Status Occupation/Employer Ht Wt (lbs) Race: Caucasian African American Hispanic Asian Other How did you hear about us? Friend Internet Magazine Other Reason for visit why are you here today? Who is your primary care physician? Is a physician currently treating you? List medication(s) you are presently taking: Are you taking any of these specific medications? Birth Control NSAIDS / Aspirin Blood Thinners Vitamin E / Herbals Testosterone Steroids Accutane Thyroid List allergies to medication(s):
7 Mansfield Cosmetic Surgery Center 550 N. Walnut Creek Drive, Ste 120 Mansfield, TX New Patient Medical History - Cosmetic Surgery Do you have any of the following conditions? AIDS High blood pressure Stroke Anemia Infection (active) Thyroid problems Arthritis Keloid scars Tuberculosis (TB) Asthma / COPD Kidney disease Ulcers Breast lumps Liver disease Venereal disease Breast cancer Chemotherapy Lupus Melanoma Diabetes Mental disorder Weight loss: How much? Dizziness Nervous disorder Weight gain: How much? Epilepsy Fainting Hay Fever Heart disease Hepatitis Radiation treatment Respiratory disorder Skin conditions Sinus problems Stomach problems Please list any other medical conditions? List all previous surgeries: Smoking History: Non-Smoker Smoker packs per day for years. Quit years ago. Do you drink alcohol? List all family history (cancer, deaths, etc) Females Only: Number of children Are you pregnant? YES NO Are you breast feeding? YES NO Any other concerns or information we should know about you? I have answered the above questions truthfully and will notify you of any changes in medications and physical conditions. Patient Signature: Date:
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
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Physician address. Physician phone
PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center www.michigansportsmedicine.com Your family physician
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form Front Office Person calls in for a new patient appointment. o Never seen at SWAN o Previously Seen at SWAN The following
SOUTH PALM CARDIOVASCULAR ASSOCIATES, INC. CHARLES L. HARRING, M.D. NEW PATIENT INFORMATION FORM. Patient Name: Home Address:
NEW PATIENT INFORMATION FORM Today s Date: Referred by: Patient Name: (First) (Last) Date of Birth: Gender: M / F SSN: Home Address: Home Phone (Area Code & No.): ( ) - Cell Phone: ( ) - Secondary Address
WORKERS COMPENSATION INFORMATION
WORKERS COMPENSATION INFORMATION PATIENT REGISTRATION INFORMATION 15215 Shady Grove Rd. # 100 Patient Name: Last First MI Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Primary Doctor:
1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics Patient s Name Birthdate Who referred you to this office? Social Security # Address City ST ZIP Home Phone Work Phone Ext Cell Phone
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
Motor Vehicle Accident - New Patient
Motor Vehicle Accident - New Patient Today's Date: Patient Name: Auto Insurance Company of Car You Were In: Phone: Insurance Agent: Phone Was A Police Report Made? Have You Informed Your Agent of Your
SHREVEPORT-BOSSIER FAMILY DENTAL CARE
SHREVEPORT-BOSSIER FAMILY DENTAL CARE Patient's Name: Patient's Birthdate: (FIRST, MIDDLE, LAST) Patient's SSN #: Patient's Email Address: _ Patient's Phone #: Home:_ Cell: Work: Patient's Address: Patient's
Name: Phone: Ins. Co: Group #: ID# Phone #: Name of Insured: Relationship to patient: SS#: / / DOB: / / Employer: Phone:
PATIENT INFORMATION Thank you for choosing us as your dental care provider. We look forward to caring for you! Patient Information: Patient Name (First Middle Initial Last): DOB: / / SS#: / / Driver s
Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 info@benjamineye.com www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C
275 Collier Road NW Suite 470 Atlanta, GA 30309 William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C www.atlantabreastcare.com Phone:
TENNESSEE NEUROLOGY SPECIALISTS AT RIVER PARK HOSPITAL. E. Frank Lafranchise, M.D.
TENNESSEE NEUROLOGY SPECIALISTS AT RIVER PARK HOSPITAL E. Frank Lafranchise, M.D. River Park Hospital 1589 Sparta Rd Ste. 205 McMinnville, TN 37110 Phone: (615) 383-8575 Fax: (978) 701-6019 IMPORTANT-
Life Insurance Application Form
Life Insurance Application Form INSTRUCTION To be completed by all applicants PERSONAL DETAILS Surname First name Middle name Sex Female Male Marital status (please tick) Single Married Other Current residential
6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick.
Adult Health History Name: First Last Name you like to be called: Today s Date: Date of Birth: Male Female Transgender Male to Female Transgender Female to Male Other Filling out this form Answering these
New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
IN CASE OF EMERGENCY
THE INFORMATION REQUESTED ON THIS FORM IS USED TO FILE MEDICAL CLAIMS AND FOR OTHER IMPORTANT MEDICAL DOCUMENTATION. PLEASE PRINT LEGIBLY SO THAT WE MAY ACCURATELY REFLECT YOUR PERSONAL INFORMATION IN
NEW PATIENT INFORMATION SHEET
Julio Garcia, MD, F.A.C.S. 6020 S. Rainbow Blvd. Las Vegas, NV 89118 (702) 870-0058 NEW PATIENT INFORMATION SHEET *Please complete before your appointment and bring it with you. Thank you. Patient Name:
SPINE PATIENT HISTORY FORM
Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print
General Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine
PO Box 297 Hedgesville, WV 25427 304 754-8803 KenBarneydds.com General Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine WELCOME TO OUR PRACTICE Welcome to the office of Dr. Kenneth C.
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
Name: Last First MI. Mailing Address: City State Zip. Email Address: Phone# (H) (W) (M)
Chart #: Patient Information Name: Last First MI Mailing Address: City State Zip Email Address: Phone# (H) (W) (M) Date of Birth: Sex: Male Female SS#: Marital Status: Single Married Divorced Widowed Separated
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION Last Name First Name MI Mailing Address City Zip code Home Phone