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Patient Information Form

    Patient Information Form

    Complete this before your appointment and your provider can be better prepared during their time with you.

    Emergency Contact

    Spouse/Parent/Guardian/Other

    Primary Insurance

    If no insurance please type "None"
    Image size should be between 0 x 0 and 4920 x 4920
    Image size should be between 0 x 0 and 4920 x 4920
    Image size should be between 0 x 0 and 4920 x 4920

    Secondary Insurance

    If no insurance please type "None"
    I have insurance coverage and assign directly all medical benefits, if any, otherwise payable to me forservices rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

    Surgery and Anesthesia History

    Specific Medical History

    Social History

    Family History

    Medications

    Allergies and Sensitivities

    I have read this questionnaire and disclosed my medical history to the best of my knowledge.

    Smoker's Waiver

    I understand that I have been advised by Dr. Vinas and his medical staff that smoking cigarettes as well as the use of all other products (Nicorette gum, patches, etc...) are harmful to patients contemplating or scheduled to undergo any surgical procedure.

    I have been advised to stop smoking IMMEDIATELY, at most 2-4 weeks prior to any surgery.

    lL understand that there are complications for any procedures, and these complications (delayed healing, and even loss of skin which could require skin grafting), could result from my surgery, in light of my history.

    I acknowledge that I reviewed the above, initiated it, to signifying my understanding of the potential risks of my having this procedure while continuing to smoke cigarettes.

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