plasticsurgeonsoflexington.com

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Welcome to Plastic Surgeons of Lexington. We're glad you've chosen us to provided you with your health care. Built on a tradition of service and excellence, our mission is to deliver the safest, highest quality, and most technologically advanced techniques with empathetic and compassionate care.
Insurance

We accept assignment and participate in most insurance plans. If you are unsure if we are in your insurance network, please check with your insurance company. Knowing your insurance benefits is your responsibility. Please contact your insurer with any questions you may have regarding your coverage to receive the maximum benefit.
Patient payment: All copayments are to be paid at the time of service. Any charges that go towards your deductible will be payable to you
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I, ________, understand that as part of my healthcare, Plastic Surgeons of Lexington, PLLC originates and maintains health records describing my health history, symptoms, examinations and test results. diagnoses, treatment, and any plans for future care or treatment. An electronic copy of your medical records is available opon request.

I have read the Notice of Information Practices and authorize Plastic Surgeons of Lexington to disclose my protected information to the following person(s):

	Name	Relationship
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2
3
4

I further understand that I retain the right to revoke this authorization in writing. I fully understand and accept the terms of this authorization. Patient or Guardian Sign:

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Same as PatientAdd a Guarantor
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Additional Information:
What are you (the patient) being seen for?
How did you hear about our office?

	Services
Dysport/Botox/Fillers
Skin Care Products
Body Contouring/SculpSure
Thin Lips
Eyelash Fullness/Thickness
Spider Veins
Facial Redness
Surgery After Massive Weight Loss
Age Spots/Freckles
Laser Treatments for Pigment, Broken Vessels, Tattoo Removal, Skin Resurfacing, Collagen Remodeling
Browlift
Drooping Eyelids
Under Eye Bags
Facial Wrinkles/Sagging
Mole Removal
Ear Size/Shape
Microneedling
Hand Rejuvenation
Red or Raised Scars
Breast Size
Breast Shape
Breast Implant Correction
Breast Reconstruction
Tummy Tuck
Upper Arm Lift
Thigh Lift
Butt Lift
Liposuction

	Time Frame
As Soon As Possible
1 to 3 Months
3 to 6 Months
6 to 12 Months
Just Need Information

Authorization:
AUTHORIZATION: I request payment of authorized benefits be made on my behalf. I assign the benefits payable for services to the physician OR organization furnishing the services and authorize such physician OR organization to submit a claim to my insurance carrier OR Medicare for payment. I consent to have my protected health information released to insurance carriers OR the Centers for Medicare & Medicaid Services and it agents OR the Social Security Administration or its intermediaries OR Any Agency, group or person(s) necessary to secure treatment, payment or business operations by the physician or organization. *For and in consideration of services rendered and to be rendered by the above listed medical provider, I hereby guarantee payment of all charges incurred for this account. *The patient or his/her representative recognizing the need for health care, consents to the above listed medical provider rendering service as ordered by the physician, including medical or surgical treatment, laboratory procedures, X-ray exams or other services rendered under the general and specific instructions of the physicians. *I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct and that Plastic Surgeons of Lexington has provided me a copy of its Notice of Privacy Practices, which provides a detailed description of uses and disclosures allowed, as well as other rights I have regarding my protected health information:
Signature of Patient or Guardian:

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Plastic Surgeons of Lexington Financial Policy
Welcome to Plastic Surgeon's of Lexington. We are glad you've chosen us to provide you with your health care. Built on a tradition of service and excellence, or mission is to deliver the safest, highest quality, and most technologically advanced techniques with empathetic and compassionate care.

Insurance: We accept assignment and participate in most insurance plans. If you are unsure if we are in your insurance network, please check with your insurance company. Knowing your insurance benefits is your responsibility. Please contact your insurer with any questions you may have regarding your coverage to receive the maximum benefit.

Patient Payment: All copayments are to be paid at the time of service. Any charges that go toward your deductible will be payable by you.
Print Patient or Guardian Name:
Signature of Patient or Guardian:

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	Family	No Issues	Family Member & Issue
Cardiovascular (heart attack/afib/stent/bypass)
High blood pressure
Respiratory (lungs/asthma/emphysema/other)
Gastrointestinal (stomach/intestines)
Musculoskeletal (muscle/bone/arthritis)
Dermatologic (skin)
Neurological (stroke/epilepsy/etc)
Endocrine (thyroid/diabetes)
Hematologic (blood/lymph nodes)
Psychiatric (depression/anxiety/etc)
Vascular disease (arteries/veins/lymph nodes)
Autoimmune Disease (R/A/lupus/etc)
Cirrhosis/fatty liver
Kidney/renal issues

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
Service Quality
Cleanliness
Responsiveness
Friendliness

Enter Patient's Information Below:

Patient's Contact Information:

Financial Policy

Insurance

Patient payment: All copayments are to be paid at the time of service. Any charges that go towards your deductible will be payable to you

Pharmacy Information:

Guarantor Information:

Emergency Contact Information:

Billing Information:

Medical & Health History

Please check any conditions that you have or have had:

Current or Previous Health Problems

Previous Surgeries:

Current Medications & Vitamins:

Additional Information:

What additional services would you like to learn about?

Authorization:

Plastic Surgeons of Lexington Financial Policy

Consent to the use and disclosure of health information for treatment, payment, or healthcare operations.

	1	2	3	4	5
When looking at my face in the mirror, I believe I look Younger, the same as, or older than my true age
When I look in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles