New Patient Intake

Legal Name (as shown on your government issued ID): *

First Name Last Name

Nickname (if preferred)

First Name Last Name

Gender *

Phone Number *

Area Code Phone Number

Alternate Phone

Area Code Phone Number

Email *

Your Birthday *

Date

Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code Country

Emergency Contact *

First Name Last Name

Emergency Contact Phone Number *

Area Code Phone Number

Employer

Occupation

Primary care physician

Reason for consultation

Other services of interest?

Eyelids Dark spots Fine lines/ wrinkles Botox/facial fillers Neck/jawline Brows Lips Nose

How did you hear about us?

Facebook Instagram Google Search RealSelf Other Referral (type name below)

Please list all medications below (prescribed and over the counter): *

If not applicable, simply enter N/A.

List any allergies below: *

If not applicable, simply enter N/A.

Preferred pharmacy name

pharmacy

Pharmacy phone

Area Code Phone Number

Do you smoke?

Y N

Are you pregnant or lactating?

Y N

Medical History: Please check if any of the following apply to you:

Medical History

	Current	Past	Never
Blood Clots*
Pacemaker*
Heart disease*
Stroke*
Cancer*
Car Accident*
High Blood Pressure
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Digestive Disease (IBS, Crohns, etc)
Allergies that Require an Epi-Pen
Autoimmune Condition
Diabetes / Insulin Resistance
Endocrine / Thyroid Condition
Chronic Depression
Chronic Anxiety
Sensitive to Touch / Pressure
Easy Bruising
Shortness of Breath / Asthma
Neurological Condition
Chronic Skin Rash
Multiple Sclerosis
Memory Loss / Confusion

Insurance carrier (if applicable)

Primary insurance

Wellness Policy

For your safety and the safety of our staff and other clients pease reschedule your appointment as soon as you are aware of an infectious or contagious condition.

If you arrive for your appointment with symptoms of an illness, you must reschedule your appointment.

If you experience any of the following symptoms, you must reschedule:

Fever or Chills
Vomiting or Diarrhea
Runny Nose
Sore Throat or Cough
You or someone in your direct care has a cold, sinus infection, flu, fever, cough.
You or someone in your direct care has been diagnosed with Covid-19 or influenza (the flu).

You are required to wear a cloth or surgical mask when you enter the office due to covid-19 precautions.

Please do not bring anyone with you to your appointment, if you require assistance please call us in advance to discuss.

Privacy Notice

Please read this information carefully. This notice explains how your personal and medical information may be used and how you can gain access to it.

When you visit a medical office and see a physician and/or any other health care provider, a record is made. This record contains information such as:

- Demographic Information
- Social Security Number
- Home Address
- Telephone Number
- Birth Date
- Health Insurance Information
- How you say you feel
- Health conditions you have
- Treatments you received
- Diagnosis and care plans
- Observations by health care providers

Health Information Uses and Disclosures

In order to serve you efficiently, there are instances when we use and disclose (give out) your health information:

Treatments
Your information will be provided to doctors, nurses and other health care workers that are involved in your care. This is necessary so that your plan of care can be carried out efficiently and effectively.

Payment
We will provide information about the care you received in our office to your insurance provider (s). On occasion, your health insurer may request details regarding procedure (s) performed during your visit. Some insurers require pre-approval for certain levels of care and we would provide the necessary information for that purpose as well. This process will help you receive benefits from your health insurer in a timely and concise manner.

Health Care Operations
To continually improve the quality of service we provide, we may use your information to conduct studies. The results are generally used to determine if our services are meeting the needs of our community. We may also contact you or send you a survey to collect comments on the service we provided to you.

Legal Requirements
If we are required by law or other regulation to release your information, we will do so. For example,

- Regulatory agencies that require information for audits, investigations and licensing due to administrative oversight.

- Reporting your information to all the necessary parties involved in a Workers’ Compensation case as required by law.

By typing my first name, last name, and providing my e-signature below,

I understand that this practice may not release my protected health information without my written consent, except in cases of Treatment, Payment or Healthcare Operations.

I understand that if I send electronic mail or text messages to the office or staff that my private health information may not be protected.

I understand that signing this document acknowledges that I have received a Patient Privacy Notice from the office of Dr. Brett Kotlus that indicates “use and disclosure” information as well as identifies and explains my patient rights.

Type Full Name: *

First Name Last Name

Signature *

Today's Date *

Month Day Year

I give the practice permission to disclose my medical condition with the following people:

List names (if applicable)

To reduce paper and office visit time please complete this form:

By typing my first name, last name, and providing my e-signature below,