Popp Cosmetic New Patient Form

New Patient Registration Form

Patient Registration
This online form is divided into 4 sections: 1) Patient Registration; 2) Medical History; 3) Financial Policy and Statement of Responsibility; and 4) HIPAA Authorization to Disclose to a 3rd Party. Please complete all of the sections in their entirety. These forms are for secure ELECTRONIC SUBMISSION ONLY. If you are having difficulty please call (402) 391-4558.
Name
First Last
Date of Birth (mm/dd/yyyy)
MM slash DD slash YYYY
Marital Status
- Single
- Married
- Widow
- Divorced
Gender
Social Security Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Cell Phone
Email
Employer
Work Phone
Work Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Person Who Carries Health Insurance
First Last
Social Security Number of Person Who Carries Health Insurance
Date of Birth of Person Carry Insurance (mm/dd/yyyy)
MM slash DD slash YYYY
Relationship to Patient:
Employer of Insured:
Work Address of Insured
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Emergency Contact
First Last
Relationship to Patient:
Phone
Referred by
Address
Referred by Address
Personal Physician
Personal Physician Address
Have You Been a Patient of Dr. Popp's in the Past?
If so, when?
Insurance Information
Primary Insurance
Policy Holder
Member ID#
Group #
Claims Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Claims Phone
Secondary Insurance
Secondary Insurance Policy Holder
Secondary Insurance Member ID#
Group #
Secondary Insurance Claims Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secondary Insurance Claims Phone
Release of Information
I hereby request and authorize the release of all information to, and from, Dr. Jeffrey Popp/Popp Cosmetic Surgery. This includes medical history, diagnosis, prognosis, laboratory work, x-ray findings and access to all hospital records and photocopies of the same.*
- Yes
Initial by checking this box
Assignment of Benefits
AUTHORIZATION: I authorize payment of benefits directly to Popp Cosmetic Surgery P.C. I understand that I am financially responsible for all charges that are not covered by my insurance.*
- Yes
Initial by checking this box
HIPPA Privacy Notice
The signature below acknowledges receipt of a copy of Popp Cosmetic Surgery P.C. Notice of Privacy Practices.*
- Yes
Initial by checking this box
Consent to Medical Treatment
I, knowing that I have (or a minor patient for whom I am guardian has) a condition requiring diagnosis and medical treatment, do hereby voluntarily consent to such diagnostic examination procedures and to such medical treatment by Dr. Popp, his assistants, or his designees as is necessary in his judgement.*
- Yes
Initial by checking this box
2-Medical History
Height
Weight
Are you in good health?
- Yes
- No
Do you have a primary care physician?
- Yes
- No
If YES, whom?
Physician's Phone #
When was your last physical exam?
Any problems?
- Yes
- No
List any drug (medication) ALLERGIES:
List all medications you are currently taking (include vitamins and supplements)
List all medical illness and conditions
Please list any surgeries (including COSMETIC) with dates:
If FEMALE, are you pregnant or planning a pregnancy?
- Yes
- No
Any problems with gums, teeth, eyes, chronic nose or sinus complaints?
- Yes
- No
If YES, please explain
Do you currently use tobacco(smoke/chew)
- Yes
- No
Occasional use?
- Yes
- No
Amount use
Are you a previous smoker?
- Yes
- No
If YES, when did you quit?
MM slash DD slash YYYY
Nicotine Usage (patch, gum lozenges)?
- Yes
- No
Amount Used
Last Used
Do you drink alcohol?
- none
- occasionally
- moderately
- excessively
Please answer the following questions as accurately as possible:
Do you have herpes or cold sore breakouts?
- Yes
- No
Do you have frequent headaches?
- Yes
- No
Do you have asthma or any chronic lung or bronchial condition?
- Yes
- No
Do you experience recurrent chest pains or shortness of breath?
- Yes
- No
Have you ever been told you have any trouble with your heart?
- Yes
- No
Do you have any abdominal problems (stomach, intestines, gallbladder, liver, hernia)?
- Yes
- No
Any trouble with your kidneys, bladder or reproductive system?
- Yes
- No
Any bone, joint or muscular trouble?
- Yes
- No
Do you have any chronic skin conditions?
- Yes
- No
Do you have any of the following: diabetes, epilepsy or high blood pressure?
- Yes
- No
Do you have Hepatitis B, AIDS or are you positive for HIV?
- Yes
- No
Have you ever been under the care of a psychiatrist or psychologist or experienced a nervous breakdown?
- Yes
- No
Have you had any marked loss or gain of weight lately?
- Yes
- No
Are you on a special diet at the present time?
- Yes
- No
Do you bleed or bruise easily or have frequent nose bleeds?
- Yes
- No
Do your cuts seem to bleed longer than other people's?
- Yes
- No
Do the blood vessels in your skin sometimes break without apparent cause?
- Yes
- No
Have you ever had any bleeding requiring the attention of a doctor?
- Yes
- No
Have you ever had a blood transfusion?
- Yes
- No
Have you ever had excessive bleeding following surgery or dental work?
- Yes
- No
Have you ever had excessive scarring or keloid formation due to surgery or vaccination?
- Yes
- No
Did you have a normal recovery following a prior surgery?
- Yes
- No
- Not Applicable
Are you extremely sensitive to anesthetics or any medicines?
- Yes
- No
Do you understand that no surgeon can GUARANTEE a good result in any operation that (s)he performs?
- Yes
- No
Do you understand that anyone undergoing any operation, no matter how minor, must assume a certain risk?
- Yes
- No
Have you ever been dissatisfied with the treatment you received from a physician or dentist?
- Yes
- No
Are you taking any of the following frequently, regularly or once in a while?
allergy shots or pills
- Yes
- No
antidepressants
- Yes
- No
arthritis medicine
- Yes
- No
sleeping pills
- Yes
- No
blood thinners
- Yes
- No
cortisone
- Yes
- No
diuretics (water pills)
- Yes
- No
eye medicine/drops
- Yes
- No
heart medicine
- Yes
- No
nose drops
- Yes
- No
thyroid medicine
- Yes
- No
vitamins or herbs
- Yes
- No
weight loss pills (prescription or herbs)
- Yes
- No
antibiotics
- Yes
- No
antihistamines
- Yes
- No
aspirin
- Yes
- No
birth control
- Yes
- No
blood pressure medication
- Yes
- No
diabetes medicine
- Yes
- No
Accutane (even last 2 years)
- Yes
- No
headache medicine
- Yes
- No
hormones
- Yes
- No
pain relievers
- Yes
- No
stomach medicine
- Yes
- No
tranquilizers
- Yes
- No
Is there a history of any of the following conditions in your family?
alcoholism
- Yes
- No
cancer
- Yes
- No
heart attacks
- Yes
- No
mental illness
- Yes
- No
allergies
- Yes
- No
birth defects
- Yes
- No
glaucoma
- Yes
- No
diabetes
- Yes
- No
bleeding tendencies
- Yes
- No
epilepsy
- Yes
- No
high blood pressure
- Yes
- No
stroke
- Yes
- No
I have completed this form fully and completely, and certify that I am the patient or legally authorized agent of the patient.
Electronic Signature*
First Last
Date (mm/dd/yyyy)*
MM slash DD slash YYYY
3-Financial Policy and Statement of Responsibility
We are pleased that you have chosen us for your health care needs. The following information regarding financial matters should be helpful to you in understanding our billing process.
For Patients with Insurance: We will bill most insurance carriers for you when proper paperwork, including insurance cards, is provided to us. We will also bill most secondary insurance companies for you. Co-payments and deductibles are due at the time of service or prior. It is the patient's responsibility to obtain any referrals that are necessary for the visit.
Medicare Patients: We will bill Medicare for you. We will also bill secondary insurance carriers for you. All co-payments, or a deductible, are due and payable at the time service is provided.
Welfare Patients: All Welfare patients must provide a CURRENT VALID card before being seen.
Liability Claims & Auto Accidents: We will file any insurance claims for services related to an auto accident or third party liability. We DO NOT however, wait for payment until settlements are complete. Payment for services is due at the time of service.
Worker's Compensation: If your injury is work-related, we will need the case number, carrier name, and information prior to your visit in order to bill the Workers' Compensation insurance company. The patient is ultimately responsible for all fees if a Workers' Compensation claim is denied.
Self Payment Accounts: We ask that you make payment at the time of the visit. We are happy to accept payment by cash, check, or credit card (except American Express). If your account reaches 90 days past due and you have not contacted us to make payment arrangements, your account may be turned over to a collection agency.
Cosmetic Services: Your initial consultation is free of charge (except breast or butt augmentation). We do ask for a credit or debit card number at the time of scheduling your appointment to ensure that you come at your scheduled date/time. If you need to cancel or reschedule at any time, we ask that you call us to do so. If there is no call to cancel and you do not come in for your appointment, there is a non refundable $100 charge. All cosmetic services and/or purchases are paid at the time of service and will not be filed with your insurance company.
For billing purposes, there COULD be four (4) separate service components which will be billed separately*
- POPP COSMETIC SURGERY CENTER OR THE HOSPITAL: You will be billed a facility fee for the use of our Ambulatory Surgery Center in which your procedure is performed. If you have questions regarding this facility fee, please contact us at (402) 391-4558.
- PHYSICIAN FEE: Dr. Popp will bill this charge separately to you/your insurance. This billing is for Dr. Popp’s professional services that are provided during your procedure. If you have questions regarding your scheduled procedure or the physician’s fee, please contact our office.
- LABORATORY AND PATHOLOGY FEE: If you have a biopsy taken you and/or your insurance will receive a bill from the laboratory that processes your biopsy.
- ANESTHESIA: If your procedure requires anesthesia at the hospital you will receive a separate bill from that anesthesia group. Anesthesia services performed at Popp Cosmetic Surgery Center are usually included in the price quote (cosmetic) or part of Dr. Popp’s surgical fee (non-cosmetic). Call our office if you have questions.
Please check each line
For the convenience of our patients, we do accept VISA, MASTERCARD and DISCOVER (AMERICAN EXPRESS NOT ACCEPTED). Our payment options include Care Credit.
I have read, understand and agree to the above financial policy for payment of professional fees. I understand the patient is ultimately responsible for all professional fees.*
- Yes
Electronic Signature*
First Last
Date*
MM slash DD slash YYYY
4-Authorization to disclose your personal health information to another party
By completing this form, you are giving Popp Cosmetic Surgery, P.C., permission to speak to another person(s) about your Personal Health Information (PHI) and to give them information such as diagnosis, course of treatment, prognosis, results of tests, how best to care for you after surgery, billing and payment specifics and any other such information as we would normally give directly to the patient.
Please list other persons, THEIR NAME AND RELATIONSHIP
If any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care options).
Electronic Signature
First Last
Date Signed
MM slash DD slash YYYY
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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(402) 391-4558

New Patient Registration Form

Patient Registration

Insurance Information

Release of Information

Assignment of Benefits

HIPPA Privacy Notice

Consent to Medical Treatment

2-Medical History

Please answer the following questions as accurately as possible:

Are you taking any of the following frequently, regularly or once in a while?

Is there a history of any of the following conditions in your family?

I have completed this form fully and completely, and certify that I am the patient or legally authorized agent of the patient.

3-Financial Policy and Statement of Responsibility

For the convenience of our patients, we do accept VISA, MASTERCARD and DISCOVER (AMERICAN EXPRESS NOT ACCEPTED). Our payment options include Care Credit.

4-Authorization to disclose your personal health information to another party

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