Registration Form

Prefix

First Name

Last Name

Is this your legal name?

Yes No

If not, what is your legal name?

What is your former name?

Gender

Male Female

Date of Birth

Age:

Social Security

Street Address line 1

Street Address line 2

City

State

Zip Code

Phone

Occupation

Employer

Employer Phone

Do you use alcohol?

Yes No

How many drinks per week?

Do you use drugs for non-medical purposes?

Yes No

Do you use nicotine/tobacco?

Yes No

How much, How long?

HAVE YOU EXPERIENCED ANY OTHER SYMPTOMS NOT LISTED ABOVE?

ARE YOU INTERESTED IN LEARNING ABOUT ADDITIONAL TREATMENTS AND/OR PROCEDURES?

Yes No

Other:

INSURANCE INFORMATION: Primary Insurance

Medicare Other

Subscriber’s S.S. Number:

Birth Date:

Group No.

Policy No.

Co-payment

Patient’s relationship to subscriber:

Self Spouse Child Other

Name of secondary insurance (if applicable):

Subscriber’s name:

Group No.

Policy No.

Patient’s relationship to subscriber:

Self Spouse Child Other

IN CASE OF EMERGENCY: Name of local friend or relative (not living at same address):

Relationship to patient:

Phone Number:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Beauty Refined Plastic Surgery or insurance company to release any information required to process my claims.

Patient/Guardian signature:

Registration Form

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