Soler-Baillo Plastic Surgery - New Patient Intake

NEW PATIENT FORM
PATIENT NAME *

First Name Last Name
TODAY'S DATE

Month Day Year
Date
ADDRESS

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
GENDER
DATE OF BIRTH

Month Day Year
Date
AGE
PLACE OF BIRTH
HOME PHONE NUMBER
WORK PHONE NUMBER
MOBILE PHONE NUMBER
EMAIL ADDRESS
example@example.com
OCCUPATION
EMPLOYER
EMERGENCY CONTACT

First Name Last Name
RELATIONSHIP
HOME PHONE NUMBER
WORK PHONE NUMBER
PRIMARY CARE PHYSICIAN
PHONE NUMBER
REFERRED BY
CONFIDENTIALITY OF MEDICAL INFORMATION

I would like medical information to only be given to (Please list the name of every person you would like medical information released to, including any physicians, family members, spouse, significant other, children, grandchildren, friends, etc.):
PATIENT'S SIGNATURE *

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MALPRACTICE INSURANCE

"Under Florida Law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE." This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against noninsured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law."
PATIENT'S SIGNATURE *

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HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare and potentially anonymous usage in a publication.

You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon the execution of this consent.
May we phone, email, or send a text to you to confirm appointments?

Yes No
May we leave a message on your answering machine at home or on your cell phones?

Yes No
This consent was signed by:

First Name Last Name
Signature *

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Date

Month Day Year
Date
ASSUMPTION OF RISK, RELEASE, WAIVER OF LIABILITY, AND INDEMNIFICATION

By signing below, you understand, acknowledge, agree, and hereby voluntarily accept all risk and responsibility associated with the services provided, and use of any of the facilities at our location.

You hereby waive all claims, assume all liability, and release hold harmless, indemnify, and agree to defend us (including our affiliates, agents, and employees.)

Soler-Baillo Plastic Surgery (SBPS, INC) affiliates and Soler-Baillo Plastic Surgery (SBPS, INC) location you may visit, from liability for any injury, claim, cause of action, suit demand, and damages (including, without limitation, personal bodily, or mental injury, property damage, economic loss, consequential damages, and punitive damages) arising from or related to:
1. Your failure to disclose any pre-existing conditions, limitations, or sensitivities;
2. Your failure to inform your therapist or esthetician of discomfort or pain during or at the end of the service;
3. Your presence on the premises our location; and/or
4. Any negligence on our part (including our employees) or on the past of any other Soler-Baillo Plastic Surgery (SBPS, INC) business.
You further expressly agree that this Assumption of Risks, Release, Waiver of Liability, and Indemnification is intended to be as broad and inclusive as permitted by law and that if any portion of it is held invalid the balance shall be valid and continue in full legal force and effect. These provisions are binding on your estate, family, heirs, administrators, personal representatives, and assigns.

YOU ACKNOWLEDGE AND AGREE THAT YOUR CONSENT TO THIS ASSUMPTION OF RISKS, RELEASE, WAIVER OF LIABILITY, AND INDEMNIFICATION IS GIVEN IN EXCHANGE FOR OUR RENDERING OR SERVICES, AND AGREE THAT THIS ASSUMPTION OF RISK, RELEASE, WAIVER OF LIABILITY, AND INDEMNIFICATION SHALL APPLY AT EACH VISIT TO OUR LOCATION.

YOU UNDERSTAND AND AGREE THAT OUR THERAPISTS AND ESTHETICIANS ARE OUR EMPLOYEES AND ARE NOT EMPLOYED BY AND ARE NOT EMPLOYEES OF ANY SOLER-BAILLO PLASTIC SURGERY (SBPS, INC) AFFILIATES.

YOU ACKNOWLEDGE AND AGREE THAT AT NO TIME SHALL YOU HAVE A RIGHT TO, NOR SHALL YOU, ASSERT OR BRING ANY CLAIM, DEMAND, OR LEGAL ACTION AGAINST SOLER-BAILLO PLASTIC SURGERY (SBPS, INC) OR ANY OF ITS AFFILIATES RELATING TO THIS AGREEMENT OR THE SERVICES PROVIDED BY US.

YOU FURTHER ACKNOWLEDGE AND AGREE THAT NEITHER SOLER-BAILLO PLASTIC SURGERY (SBPS, INC) NOR ANY OF ITS AFFILIATES SHALL WE HAVE ANY LIABILITY FOR:
1. ANY OBLIGATIONS OR LIABILITIES RELATING TO OR ARISING FROM OUR RENDERING OF SERVICES TO YOU;
2. ANY CLAIM BASED ON, IN RESPECT OF, OR BY REASON OF THE RELATIONSHIP BETWEEN YOU AND US;
3. ANY CLAIM BASED UPON ANY ALLEGED UNLAWFUL ACT OR OMISSION BY US OR ANY SOLER-BAILLO PLASTIC SURGERY (SBPS, INC) LOCATION.
Name

First Name Last Name
Signature *

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Date

Month Day Year
Date
Please verify that you are human *
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NEW PATIENT FORM

HIPAA Compliance Patient Consent Form