New Patient Packet: Accessible Version

Patient information.

Information to fill in

• First name
• Last name
• Date of birth
• Address, city, state and ZIP code
• Home phone
• Cell phone
• Work phone
• Email address
• Driver's license number (please give a copy to the front desk)
• Social Security number
• Gender: female or male
• Marital status: single, married, divorced or widowed
• Emergency contact, their relationship to you, and their phone number
• How were you referred to us? Website, friend, family, doctor (name of referral), or other

As required by the Health Information Portability and Accountability Act (HIPAA) of 1996, you have a right to request that communications concerning your personal health information be made through confidential channels. This medical practice will not ask you why you are making your request, and will make reasonable efforts to accommodate all reasonable requests. Some methods of contact must be provided, and as appropriate, information as to how communication will be handled.

I (print name), [blank], hereby request the use of the following confidential channels for the communication of information related to my personal health, treatment, or any matters relating to the care I am receiving at Finesse Plastic Surgery. This request supersedes any prior requests for confidential channel communications I may have made.

Please select all that apply. For each item, choose DO or DO NOT.

Phone

• I want you to contact me by telephone.
• Leave messages on my answering machine.
• Leave messages with any other person.
• Please indicate name(s), if any, of the individual(s) approved to take the above messages: [blank]

Email

• Contact me via email.

Mail

• Contact me via mail.

Diagnosis and treatment

• Want you to discuss my diagnosis, treatment, or any health related matters with my family members or anyone on my behalf.

Please indicate name(s), if any, of the individual(s) approved to speak to members of your family or anyone on your behalf regarding your diagnosis, treatments, or any health related matters: [blank]

If not signed by patient, please indicate relationship: parent or guardian of minor patient; guardian or conservator of an incompetent patient; or beneficiary or personal representative of deceased patient.

Information to fill in

• Your printed name
• Your DO or DO NOT choices above
• Approved names, if any
• Relationship, if not signed by the patient
• Patient signature
• Date

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort contract, or otherwise, and shall bind all parties whose claims may rise out of or in any way relate to treatment or services provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as "Physician") to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses, and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/her claims with reasonable diligence, and the arbitration shall be governed pursuant to the Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees, and expenses, along with a pro rata share of the neutral arbitrator's fees and expenses.

Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well.

Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient.

Article 6: Severability Provision: In the event of any provision(s) of this Agreement is declared void and/or unenforceable, such provisions(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with California law.

I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy.

Notice: by signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See Article 1 of this contract.

Note: the printed form labels both of its first two articles "Article 1". This version numbers them 1 and 2 so they are easier to tell apart; the text is unchanged.

Information to fill in

• Physician's or duly authorized representative's signature (completed by the practice)
• Medical group name: Finesse Plastic Surgery (pre-filled)
• Patient's signature and date
• Patient's printed name and date of birth
• Signature of translator, if applicable, with date, and printed name of translator
• Patient's representative's signature, if applicable, with date, and their printed name and relationship to the patient

Finesse Plastic Surgery is committed to providing you with top quality care. As a part of your care, we believe it is important to you to be informed about our financial policy as outlined below.

Missed Appointments and Cancellation Fee

At Finesse Plastic Surgery, we have reserved your appointment especially for you. We would appreciate your understanding and cooperation with regard to cancellation. Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving treatment. Absent of an emergency, Finesse Plastic Surgery reserves the right to charge a fee of $150.00 for all missed appointments, ("no shows") and appointments which are not cancelled with a 24-hour advance notice. "No Show" fees will be billed to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. If you find that you must cancel, please do so at least 24 hours prior to your scheduled time. If appointments are not cancelled within the designated time, your credit card and/or account will be charged $150.

Returned Check Policy

If a check is returned to us for non-payment of insufficient funds, we will assess a $25.00 fee to your Finesse account and you will be billed accordingly.

All Patients

My signature below represents my acknowledgment of the financial policy as outlined above. I further understand that I will be held financially responsible for any and all charges denied by my health plan and/or if I present with no insurance benefits.

Information to fill in

• Name (please print)
• Date of birth
• Signature
• Date

I, [print patient name], consent to the taking of photographs by the staff of Finesse Plastic Surgery of me or parts of my body in connection with the plastic surgery procedure(s) intended or performed. I understand that photographs may be taken before, during, and after my procedure(s) as a routine part of my medical care. I understand that I will never be identified by name in any use of these photographs, but that in some circumstances the photographs may portray features which make my identity recognizable.

I release and discharge Finesse Plastic Surgery from all rights that I may have in the photographs and from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of the photographs. I certify that I have read the above Authorization and Release and fully understand its terms.

This consent may be revoked at any time with a written consent.

Information to fill in

• Print name
• Date
• Signature
• Staff signature (completed by the practice)

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You can read the Notice of Privacy Practices on this website.

You have the right to request that we restrict how protected health information about you for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

• Protected health information may be disclosed or used for treatment, payment, to determine research eligibility, review of clinical data associated with participation in a research trial, or health care operations.
• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
• The Practice reserves the right to change the Notice of Privacy Practices.
• The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
• The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
• The Practice may condition receipt of treatment upon the execution of this Consent.

Information to fill in

• Name (print name)
• Signature and signature date
• Relationship to the patient (if other than the patient)
• Witness: printed name of practice representative, with signature date (completed by the practice)

I hereby permit, Finesse Plastic Surgery hereinafter "You" or "Your" to photograph, make audio recording, video tape recording or written message in the likeness of [patient name].

Description of usage. The printed form lists these uses, each already marked with an X: website, affiliated websites, news segment, brochure, print, social media, television, radio.

In addition, you agree to be identified by name in the above reference: yes or no.

I grant to You, Finesse Plastic Surgery and/or Your affiliates, successors, or other persons acting under Your permission and authority, the irrevocable, perpetual, unrestricted, royalty free right, license and permission to copyright in Your own name, and to use, re-use, publish, reproduce and distribute, such audio and/or video recordings, pictures, composites, or other reproductions thereof, distorted or modified in form or character, without restriction as to changes or alterations, whether in conjunction with the subject's true or fictitious name or in conjunction with other photographs or printed matter, made through a medium, including website publishing, for illustration, education, promotion, art, editorial, advertising, trade, or any purpose whatsoever, in such manner as you deem appropriate for such purposes. I understand that if such picture or image, or recording is published on the web, it may be downloaded by any computer user. You agree not to use the photograph/recording/image in any derogatory manner.

I waive the right to inspect or approve the finished product(s) and/or advertising copy or other matter used in connection with the product or the use for which it may be applied. I further waive any claims to royalties or monetary compensation connected with such recordings, creations or photographs, or the publication or distribution thereof.

My signature below confirms that I have the legal right to grant this license to You. I hereby release, discharge, and agree to hold You and/or Your affiliates, successors, or those acting under Your authority or permission, harmless from any liability connected with the photography, recording or creation or the use, re-use or publication of such images or recordings, including blurring, distortion, alteration, cropping, or the use in composite form, intentional or otherwise, that may occur or be produced in the processing of such products. This consent shall be binding upon me and the subject of this photography, or recording (if different), my heirs, agents, legal representatives, and assigns.

Accepted and agreed.

Information to fill in

• Patient name
• Identified by name: yes or no
• Signature
• Date
• Print name
• Witness (completed by the practice)