Social Media Photo Release Form

PRINT-ONLY FORM
- MAY PRINT AND FILL OUT MANUALLY AND TAKE TO THE OFFICE
- MAY FILL OUT ONLINE AND PRINT TO TAKE TO THE OFFICE
PATIENT DEMOGRAPHICS
PATIENT'S Name
Patient's Full Name
Patient's Date of Birth

MonthDayYear
Date
Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Responsible Party Information
Father
Father's Full Name
Father's Date of Birth

MonthDayYear
Date
Is Father's Address Same As Patient's?

YesIf No, (please fill address below)
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number
Cell Number
Email
example@example.com
Father's Social Security Number
Mother
Mother's Full Name
Mother's Date of Birth

MonthDayYear
Date
Is Mother's Address Same As Patient's?

YesIf No, (please fill address below)
Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number
Work Number
Email
example@example.com
Mother's Social Security Number
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship
Emergency Email
example@example.com
Emergency Phone Number
Insurance Information
Insurance Name
Insurance Phone Number
Policy#
Group#
Employer Phone Number
Insurance Name
Policyholder Name

First NameLast Name
Policyholder Date of Birth
Policyholder Social Security Number
I have read and understood the information provided above and confirm my information is accurate for the following form:

1) Consent for Treatment

2) Photo Authorization & Release

3) Patient Demographics & Medical History

4) Payment Information

I authorize the release of any medical or other information necessary to process my insurance claim. I also authorize payment of medical and surgical benefits to Microtia Congenital Ear Deformity Institute/Arturo Bonilla, M.D.
Signature of Parent/Legal Guardian

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Date

MonthDayYear
Date
PATIENT MEDICAL HISTORY
Patient's Name
Patient's Full Name
Patient's Date of Birth

MonthDayYear
Date
Past Medical History
Any medical conditions or illnesses?

NoYes
If yes, please describe
Surgical History?

NoYes
If yes, please describe
Is your child taking any medications?

NoYes
If yes, please describe
Is your child allergic to any medications?

NoYes
If yes, please describe
Has your child had a CT Scan?

YesNo
Has your child had an audiogram (hearing test)?

YesNo
Signature of Parent/Responsible Party

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Date

MonthDayYear
Date
CONSENT FOR TREATMENT
Patient's Name
Patient's Full Name
Parent/Legal Guardian/Other
Person responsible for treatment of patient
What is your relationship to the patient?

ParentLegal GuardianOther (please specify)
I authorize the following persons to make medical/surgical decisions only when necessary
Name
Name
Name
Name
I hereby give consent to Dr. Arturo Bonilla to examine and administer any medical and surgical care (when necessary) for Patient's Name.
Signature of Parent/Legal Guardian

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Date Signed

MonthDayYear
Date
PHOTO AUTHORIZATION & RELEASE

For minors 18 years and younger
In the spirit of education and inspiration for our families and children with microtia, we ask parents to grant us permision to occasionally post our patient's pictures on our website or social media pages (usually Facebook).

If allowed, please fill out and sign the appropriate statement to either allow or decline permission to use pictures of your child on the Microtia - Congenital Ear Deformity Institute/Dr. Arturo Bonilla, M.D. website/social media.

Our website/social media has many visitors and your child's photo would be available to the visiting general public. The Microtia - Congenital Ear Deformity Institute/Arturo Bonilla, M.D. assumes no liability or responsibility whatsoever concerning any consequences of such use. If requested by the parents, we will remove any picture on the website as soon as possible.
Patient's Name
Patient's Full Name
PARENT'S Name
Parent's Name
What is your preference regarding the use of your child's photo as stated above?

I DO consent to the use of my child's photo as stated above.I DO NOT consent to the use of my child's photo as stated above.
If you DO consent, what are your preferences?

I consent to FIRST NAME ONLY.I consent to INITIALS ONLY.I consent to the use of photo's anonymously.
Signature of Parent/Legal Guardian

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Date Signed

MonthDayYear
Date
PAYMENT INFORMATION
Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your medical bills is considered a part of your treatment. The following is a statement of our financial policy, which we require you to read, agree to and sign prior to any treatment.

PAYMENT IS DUE AT THE TIME OF SERVICE

We accept Cash, Checks, Visa, MasterCard, American Express, Discover and CARE CREDIT

REGARDING INSURANCE

Our office is pleased to file claims with your insurance company for reimbursement of your medical services.

• The patient is responsible to pay any deductible and co-payments at the time services are rendered.

• It is your responsibility to know if a referral is necessary for your visit.

• Any portion of a billed amount that is labeled “disallowed” or “not covered” will become the patient’s responsibility.

• Our office NEVER guarantees that your insurance will pay. We will make every attempt at the beginning of your health care to receive verification of your policy benefits. However, if for some reason your insurance claim is denied, you are responsible for the amount due on your account.

• Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. While we are committed to provide quality medical care for you, any questions or issues must be resolved by you with your insurance company.

NSF CHECKS

All returned checks will be assessed a $35.00 fee. Thank you for understanding our financial policy.

I have read, understand and agree to the provisions of this financial policy.
Patient's Name
Patient's Full Name
Signature of Parent/Legal Guardian

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Date Signed

MonthDayYear
Date
Should be Empty:

PATIENT DEMOGRAPHICS

PATIENT MEDICAL HISTORY

CONSENT FOR TREATMENT

PHOTO AUTHORIZATION & RELEASE

PAYMENT INFORMATION