LPS Patient eRegistration

Today's Date:

MonthDayYear
Date
First Name:
Last:
M.I.
Street Address:
City:
State:
Zip Code:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Sex:
Birthdate:

MonthDayYear
Date
Social Security #:
000-00-0000
Ethnicity:
Procedure(s) of Interest:
OCCUPATION

Insurance
Employer:
Employer Address:
INSURANCE
Primary Insurance Co.
Name of Policy Holder/Guarantor:
Relation to Patient:
ID #:
Group #:
Pharmacy
Pharmacy Name:
Pharmacy Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
City:
Emergency Contact
Name:
Relation:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Dr. Gerstle is interested in knowing about your general health so he may plan your surgery/treatment as carefully as possible. This form is CONFIDENTIAL.
General Health:
Marital Status:
Height:
Weight (lbs):
Drug Allergies?
If yes, please list medication and reaction.
Other allergies?
Any medications, vitamins, over-the-counter herbal preparations/supplements? If yes, please list below the name of medication, strength (mg), frequency, and reason for taking it.
Have any family history of cancer, heart trouble, or stroke? Yes or No (Specify)
Do you engage in a regular exercise program?
Consume regular amounts of alcoholic beverages?
Amount and frequency?
Use tobacco/nicotine products?
Drug Use?
If yes, please specify.
Do you have a skincare regimen?
If yes, please specify.
Have any current or previous use of cortisone/steroids?
If yes, please specify.
Do you have problems with general anesthesia?
Any family history of issues with anesthesia? If yes, please specify.
Please list all surgical procedures you have undergone. Include year, procedure, location, and surgeon.
General Health

Please check yes or no if any of the following apply:

Rows	Yes	No
Serious illness lately
Anemia
Nervousness
Drug Habit/addiction
Psychiatric treatment
Blackouts or epilepsy
Shortness of breath
High blood pressure
Diabetes
Thyroid problems
Susceptible to cold sores
Hidradenitis suppurativa

Heart

Please check yes or no if any of the following apply:

Rows	Yes	No
Heart Trouble
Heart Attack
Palpitations/irregular or extra beats
Angina (chest pain)
Abnormal EKG
Rheumatic heart disease
Heart failure

Lungs

Please check yes or no if any of the following apply:

Rows	Yes	No
Asthma
Bronchitis
Tuberculosis
Pneumonia
Smoker's cough
Emphysema

Kidneys

Please check yes or no if any of the following apply:

Rows	Yes	No
Infections
Kidney Damage
Kidney failure

Blood

Please check yes or no if any of the following apply:

Rows	Yes	No
Bleeding tendency
Blood transfusions
Blood Clots/DVT

Breast

Please check yes or no if any of the following apply:

Rows	Yes	No
Cyst, tumor, or lump
Breast biopsy
Nipple discharge
Mammogram

Eyes

Please check yes or no if any of the following apply:

Rows	Yes	No
Visual Problems
Wear contacts
Wear glasses
Use eye drops

Nose

Please check yes or no if any of the following apply:

Rows	Yes	No
Broken nose
Difficulty breathing
Use nose spray

Liver

Please check yes or no if any of the following apply:

Rows	Yes	No
Hepatitis
Cirrhosis (Alcohol disease)

Intestinal

Please check yes or no if any of the following apply:

Rows	Yes	No
Stomach Ulcers
Colitis
Gallstones

Do you have an Advanced Directive?
Would you like a copy of our Patient Rights and Responsibilities?
Would you like a copy of our Notice of Privacy Practices?
Primary Care Physician Name:
Primary Care Physician Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Date of your last physical exam:

MonthDayYear
Date
Date of most recent mammogram:

MonthDayYear
Date
Date of any recent lab work (if applicable):

MonthDayYear
Date
How did you hear about us?
Payment Policy

All professional services rendered are charged to the patient and are due and payable prior to the time of service. Past due accounts greater than thirty (30) days will be subject to an interest fee of 1.5% per month. Past due accounts may also be subject to attorney’s fees, collection fees, legal fees, and / or court costs incurred as a result of our attempt to collect the debt. A service fee of $25.00 will be assessed for each returned check. Lexington Plastic Surgery is a self-pay practice and does not bill insurance. Payment is due at the time of service. A 2.5% processing fee applies to all credit card transactions. Patients may avoid this fee by paying via cash, check, or debit card. I understand that I am financially responsible for all payments related to my treatment. A copy of this signature is as valid as the original. I understand that all payments for consultations, procedures, and surgery deposits are non-refundable. Payments may be applied toward future treatments or procedures.
Signature of Patient or Personal Representative:
Date:

MonthDayYear
Date
Signature of Policy Holder:
Date:

MonthDayYear
Date
Consent to Photograph

I understand that photographs may be taken before and after my treatment or procedure at Lexington Plastic Surgery™ for medical documentation, educational, and/or marketing purposes. I authorize the use of these photographs for any lawful purpose, including display on the practice’s website, social media, and other promotional materials, only as approved by Dr. Gerstle. I understand that every effort will be made to maintain my privacy and confidentiality. Identifying features, such as my face or tattoos, will not be used without my additional written consent. I understand that I may withdraw my consent for the use of my photographs for marketing purposes at any time by submitting a written request to Lexington Plastic Surgery™
Signature of Patient or Personal Representative:
Date:

MonthDayYear
Date
I acknowledge that I have been offered a copy of the Practice's Notice of Privacy Practices, which explains how my medical information may be used and disclosed and outlines my rights regarding that information.
Signature of Patient or Personal Representative:
Date:

MonthDayYear
Date
Type a question:
Should be Empty:

OCCUPATION

INSURANCE

Pharmacy

Emergency Contact

General Health

Heart

Lungs

Kidneys

Blood

Breast

Eyes

Nose

Liver

Intestinal

Payment Policy

Consent to Photograph