for AESTHETIC VULVOVAGINAL SURGERY

...and thanks you for selecting us for your healthcare needs. We are dedicated to providing you with the best personalized healthcare and solutions. To help us do this, please fill out this form completely in ink. If you have any questions or need help, please ask us. We will be happy to help you. Complete this form prior to your visit if possible.

Who is responsible for this account?

Primary Insurance

Secondary Insurance

I hereby assign all medical/surgical benefits to the Alinsod Institute and understand that I am financially responsible for all charges. I hereby authorize the release of information necessary to secure the payment of benefits. I further agree that a photocopy of the agreement shall be as valid as the original.

HIPAA Notice of Privacy Practice

How We Collect Information About You: South Coast Urogynecology and its employees and collect data through the following but not limited to the submission of the Health and Physical (H&P) registration forms, letters, phone calls, emails, and office notes either required by law, or necessary to process requests for medical care through our organization.

What We Do Not Do With Your Information: Information about your financial status and medical conditions and care that you provide to us in writing, by phone, via email (including information left on voice mails), contained in or attached to your medical chart, or directly or indirectly given to us, is held in the strictest confidence.

We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about patients or clients who receive our services that is considered patient confidential, is restricted by law, or has been specifically restricted by a patient or client.

How We Do Use Your Information: Information is only used as is reasonably necessary to provide you with health care services which may require communication between South Coast Urogynecology providers, medical produce or service providers, pharmacies, insurance companies, and other providers necessary to: verify your medical information is accurate; determine the type of medical supplies or any health care services you need including but not limited to; or to obtain or purchase any type of medical supplies, devices, medications, insurance.

If you apply or attempt to apply to receive assistance through us and provide information with the intent of purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.

Information We Do Not Collect: We do not use cookies on our website to collect data from our site visitors. We do not collect information about site visitors except for a hit counter that simply records the number of visitors and no other data.

Limited Right to Use Non-Identifying Personal Information From Biographies, Letters, Notes, and Other Sources: Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of South Coast Urogynecology. We reserve the right to use non-identifying information about our patients or clients (those who receive services or goods from or through us) for fundraising and promotional purposes that are directly related to our mission.

Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without client's express advance permission.

You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent.

 

Authorization to leave messages

PAYMENT POLICY FOR AESTHETIC SURGERY

Dr. Alinsod is the leading surgeons in his field of expertise and takes great pride providing quality and confidential care. Patients are exceptionally valued and provided extensive consultation time with both Dr. Alinsod and our patient liaison, enabling all questions and concerns to be addressed well in advance of scheduled surgery.

As you can imagine, surgical slots are at a premium. A great deal of thought has been given for evaluation, preparation, surgery time, and staffing needed for each procedure. In consideration for Dr. Alinsod's time, staff members, and fellow clients, we have an unwavering financial policy.

A 50% deposit is required at the time of scheduling surgery. This allows us to block the time needed for your surgery. The remaining balance is due one week prior to surgery. All fees must be received one week prior to surgery. A non-refundable 50% of the deposit will be retained for a cancelled surgery that is not reschedule with Dr. Alinsod.

We accept cash, all major credit cards, and cashiers checks. Personal checks are not accepted.

Please note, additional surgical procedures cannot be added on the day of surgery unless payment in full has been received.

 

I have read and understand the Payment Policy for Aesthetic Surgery and agree to abide by its guidelines.

INITIAL HISTORY AND PHYSICAL

_________________________

 

 

 

 

BIRTH CONTROL:

 

 

 

 

HORMONE QUESTIONNAIRE:

Are you experiencing any of the following symptoms?

 

 

 

 

FAMILY HISTORY (check illness which has occurred in any blood relative and write relationship to you):

SOCIAL HISTORY

 

 

REVIEW OF SYSTEMS:

Please answer each question by checking the best response between "not at all" and "greatly".

 

Urogenital distress inventory

Family History Questionnaire for Common Hereditary Cancer Syndromes

Please mark below if there is a personal or family history of any of the following cancers. If yes, then indicate family relationship and age at diagnosis in the appropriate column. Consider parents, children, brothers, sisters, grandparents, aunts, uncles, and cousins.

EXAMPLE:

Colorectal cancer

YOU: 33yrs

SIBLINGS/CHILDREN: Brother 36yrs

MOTHER'S SIDE: Aunt 44yrs, Cousin 58yrs

FATHER'S SIDE: Grandfather 65 yrs

This chart is a record of your fluid intake, voiding and urine leakage.

Choose 4 days (entire 24 hours) to complete this record - they DO NOT have to be in a row.

Pick days in which will be convenient for you to measure EVERY void. 

 

INSTRUCTIONS:

1. Begin recording upon rising in the morning-continue for a full 24 hours.

2. Record separate times for voids, leaks and fluid intake.

3. Measure voids in "cc's" using the hat.

4. Measure fluid intake in ounces.

5. When recording a LEAK - please indicate the Volume ("1=drops/damp, 2=wet-  soaked, or 3=bladder emptied"), your activity during the leak, and if you had an urge ("yes" or "no")

 

EXAMPLE:

 

7:00am      250cc            2           Running         Yes                         _____

 

7:30am     _______      ____       __________    _______      _8 oz./Herbal tea