• Patient Information

  • Date of birth*
     - -

  • Patient contact information

  • Ok to leave a detailed message?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to receive email notifications?*

  • Medical Information

  • Other concerns / areas of interest (check all that apply)
  • For you, is this weight
  • Do you now or have you ever smoked?*
  • Do you drink alcohol?*
  • Do you use recreational drugs?*
  • Do you have ANY DRUG OR LATEX ALLERGIES, or reactions to any medicines?*
  • Have you or a family member had problems with anesthesia?*
  • When you go to the dentist, do you have a hard time getting or staying numb?*
  • Do you have bruising or bleeding problems?*
  • Do you have any family history of Glaucoma or Cancer?*
  • Check any and all of the following symptoms you have or have had in the past year
  • Check any and all of the following conditions you have now or have had in the past

  • Eye and facial history

  • Do you have any visual problems?*
  • Do you wear glasses or contacts?*
  • Do you have dry or watery eyes?*
  • Do you have glaucoma?*
  • Have you had Bell's Palsy?*
  • Have you had any injury to your eyes?*
  • Have you ever had cataracts?*
  • Have you had laser or other eye surgery?*

  • Past surgical history

  • Additional information

  • Date*
     - -

  • Photographic Consent

  • In connection with the medical services that I am receiving from Wenjing Liu, M.D., I consent that photographs and / or videos may be taken of me before, during, and after treatments. 

  • Please select one of the following:*
  • Date*
     - -

  • Consultation Questionnaire

  • My three biggest concerns are
  • Do you have any particular dates in mind?
     - -

  • Insurance information

    (you may leave blank if you are only having a cosmetic procedure)
  • Are you ONLY having a cosmetic procedure?*

  • Primary insurance

  • Policy Holder's Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Billing address is the same as the patient's*
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  • Secondary insurance

  • Do you have secondary insurance?*
  • Policy Holder's Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Billing address is the same as the patient's*
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  • Date*
     - -

  • Primary Care Physician

  • Format: (000) 000-0000.

  • Pharmacy information

  • Format: (000) 000-0000.

  • Emergency contact information

  • Format: (000) 000-0000.

  • Other information

  • Format: (000) 000-0000.

  • Missed appointment and cancellation policy

  • In order to be respectful to the needs of other patients, our office requires a 24-hour notice of cancellation of your appointment. In the event that you miss or fail to cancel your appointments in a timely manner, a fee of $100 may be charged. This fee must be paid prior to scheduling future appointments.

    You may call (949) 200-6838 and leave a message or email info@wliumd.com at any time when you realize that you will be unable to keep your scheduled appointment. If you arrive more than 20 minutes late, we may have to reschedule your appointment. Exceptions to this policy will be made on a case-by-case basis. Thank you for your understanding.

  • Date*
     - -

  • HIPAA Acknowledgement and Notice of Privacy Practices

  • This summary of our privacy practices is a condensed version of our Notice of Privacy Practices. Our full-length Notice is available for viewing on our website or in the office.

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care of you, and the services and / or items we provide to you as our patient. By law, we are required to make sure that your Protected Health Information is kept private.

    How will we use or disclose your information? Here are a few examples (for more details please refer to the complete Notice of Privacy Practices):

    • For medical treatment
    • For appointment reminders
    • To obtain payment for our services
    • To avert a serious threat to health or safety
    • In response to requests arising out of lawsuits

    If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

    You have certain rights regarding the information we maintain about you. These rights include:

    • The right to inspect and copy
    • The right to amend
    • The right to an accounting of disclosures
    • The right to request restrictions
    • The right to a paper copy of this notice
    • The right to request confidential communications

    For more information about these rights, please see the detailed Notice of Privacy Practices.

  • Date*
     - -

  • State of California Required Notices

  • Open Payments Database

    The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms. gov.

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