* Do you have a personal physician?
About your insurance Please be sure to give the receptionist your insurance card(s) when you visit.
Whose employer provides insurance (if different than patient)
Secondary Insurance Information
Do you have a secondary insurance?
Present Illness
Do you use recreational drugs?
About Your Medical History Have you had any of the following conditions? (Check box for yes or leave blank for no)
Ears, Nose, Mouth and Throat
Are you taking any of the following drugs? (check box for yes and leave blank for no)
Please list current medications and include any dosage and frequency
Please list all operations and the year and reasons for the operations
Please list all hospitalizations and the year and reasons for the hospitalizations
I, the undersigned, affirm that the information I have given is correct to the best of my knowledge. I authorize treatment of the person named
as "patient". I understand that Facial Plastic and Cosmetic Surgery Center will file with my primary insurance company for services rendered
and authorize payment of medical insurance benefits directly to FPCSC. I understand that I am responsible for paying any co-payment and
deductibles that my insurance does not cover. I authorize FPCSC to obtain or release any information that is related to the treatment of
the "patient". A photocopy of this authorization shall be considered as effective and valid as the original document.