Patient name: ___________________________________date of birth: ______

PATIENT NAME ______________________________________________________________ SEX _______ AGE _________ ADDRESS ______________________________________________________________HOME PHONE __________________ SOCIAL SECURITY # _____________________DATE OF BIRTH _______________ CELL PHONE __________________ PATIENT’S EMPLOYER _________________________________________________ EMP. PHONE ___________________ SPOUSE’S NAME _______________________________________________SPOUSE CELL PHONE ___________________ PARENT/LEGAL GUARDIAN: ____________________________________RELATIONSHIP_________________________ PRIMARY DOCTOR ____________________________________________ REFERRED BY __________________________ PURPOSE OF VISIT _____________________________________________________________________________________ INJURY/ONSET DATE ___________________ WORK RELATED ACCIDENT? YES NO or AUTO? YES NO IF ACCIDENT, HOW AND WHERE OCCURRED _______________________________________________________ INSURANCE INFORMATION:
INSURANCE _______________________ SUBSCRIBER ______________________________ DOB_______________ POLICY/ID# ________________________GROUP # __________________ EMP NAME ________________________ SECOND INS _______________________ SUBSCRIBER ______________________________ DOB_______________ POLICY/ID# ________________________GROUP # __________________ EMP NAME ________________________ USE AND DISCLOSURE OF INFORMATION ABOUT YOU
Initial _____ Spokane Plastic Surgeons, PS may use and disclose information about you and your health to diagnose and treat you, obtain payment for your care, and for its health care business operation. The manner in which Spokane Plastic
Surgeons, PS may use information about you is explained in the “Notice of Privacy Practices”, which has been
provided to me.
_____ Spokane Plastic Surgeons, PS may leave a message for the patient(s) regarding appointments and rescheduling. _____ Spokane Plastic Surgeons, PS may disclose information about patient’s care to: _________________________________________________ _____________________________________________________ AUTHORIZATION FOR TREATMENT AND FINANCIAL RESPONSIBILITY STATEMENT
I hereby certify that the information given is true and correct to the best of my knowledge. I also hereby authorize Lynn D Derby, MD and Edwin Y Chang, MD to furnish information to my insurance and your insurance carrier, if need arises, concerning illness/treatments, and I hereby assign to the physician(s) all payments for medical services rendered to myself or dependents. I understand that I am responsible for any amount not covered by the insurance. A photocopy of this release is considered valid as the original. By signing this document, I certify that I am of lawful age and legally competent to consent to this authorization for treatment. _____________________________________________________ _____________________________________________________ Signature of Patient Representative/Agent Patient’s Name: ________________________________________________________________
Current height: _______ Current weight:_______ lbs. If hand injury: Right – Left - Bilateral
Blood disorders:
Y N Pacemaker/defibrillator
Other Health
Problems:
Joint disease:
Personal Health &

Endocrine:
Gastrointestinal/
Bladder:
Heartburn/reflux
Are You On:
Mental/Emotional:
Neurological:
or stents
Heart murmur
Patient’s Name: ________________________________________________________________ List ALL allergies
Reactions
List ALL medications, vitamins & herbal supplements:
List ALL past surgeries:
List ALL surgery, anesthesia & medication
complications
Other Health Information not previously mentioned:

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Source: http://spokaneplasticsurgeons.biz/images/SPS_NewPatientForm.pdf