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Kami parsa, m

Kami Parsa, M.D.
465 N. Roxbury Drive, Suite 1001, Beverly Hills, CA 90210 Date: _________________________________ Name: ________________________________________________ Age: _____________ DOB: _______/______/______ Address: ______________________________________City_______________________State_______ Zip________________ Home Tel: ________________________________Cell:______________________________Wk Tel: _____________________ Email: _________________________________________ SS# _____________________________________ Primary Physician: _____________________________________ Phone #_________________________________________ How did you hear about Dr. Parsa ?_________________________________________________________________________ Have you been to our website?______________ Was our website helpful? No Yes If No, pls. list reason: ______________________________________________________________________________________________________ Is it ok to send mail to your address: No Yes Email Blast: No Yes Leave messages on #‟s above: No Yes What is the reason for your visit today? (Circle all applicable procedures below) Cosmetic
Functional
Please describe your visit for today: ________________________________________________________________________ _____________________________________________________________________________________________________ Have you consulted with other physicians about procedure(s) indicated above: No Yes If Yes, please describe your understanding of the procedure(s)____________________________________________________ Is this procedure a revision from a previous surgery No Yes If yes, how many previous surgeries?_____________________ What is your “ideal time frame” for procedure(s) completion _______________________________________________________
Employer _______________________ Address ______________________________________________________________
Occupation: _____________________________________________ Marital Status: _________________________________

Primary Insurance Co
. ____________________________________ Policy # ______________________________________

Group # _______________ Name of person insured __________________________________ SS# ____________________
Eligibility Phone # _________________________________________ Copay ______________________________________
Secondary Insurance Co. ____________________________________ Policy # ____________________________________
Group # _______________ Name of person insured __________________________________ SS# ____________________
Eligibility Phone # _________________________________________ Copay _______________________________________ HEALTH INFORMATON
Do you have any chronic medical problems? (Circle all that apply) Is there a personal or family history of anesthetic complications? No Yes If yes, please explain_____________________________________________________________________________________ Do you have a family history of any medical problems? (Circle all that apply) Please indicate family member. 1._________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________ 5. ________________________________________ Please list all prior Hospitalizations: 1._________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________ 5. ________________________________________
Please list ALL medications and/or dietary supplements including:
(Prescriptions, Over the Counter Medicines, Aspirin, Vitamins and Herbal Supplements such as Fish Oil, Saw Palmetto,
Flax Seed Oil and St. John’s Wort)

1. _____________________________________________ 6. _____________________________________________ 2. _____________________________________________ 7. _____________________________________________ 3. _____________________________________________ 8. _____________________________________________ 4. _____________________________________________ 9. _____________________________________________ 5. _____________________________________________ 10. ____________________________________________
Please list ALL allergies and describe reactions: (i.e. Shellfish, Latex, Penicillin, etc).
1. _____________________________________________
4. _____________________________________________ 2. _____________________________________________ 5. _____________________________________________ 3. _____________________________________________ 6. _____________________________________________ Social History: Have you ever used tobacco products? No Yes If yes, how long?__________ how much?__________ Which tobacco product(s) have you used?____________________________ If you are a former smoker, state the year you stopped: __________________ Past or current use of Nicotine Gum, Patch, or any other type of stop-smoking aid: No Yes If yes, please list: _______________________________________________________________________________________ Alcohol Consumption: _________Never (Do not consume alcohol) ________ Rare (1-2 drinks a week) _________ Moderate (7-10 drinks a week) _______ Heavy (daily or more than 10 drinks a wk) Did you ever drink heavily in the past? No Yes Are you feeling hopeless about the present/future? No Yes Do you currently have thoughts of harming yourself? No Yes Review of Systems: Please answer the following Yes or No questions to the best of your ability. Do you have any of the following conditions, illnesses or symptoms? Shortness of Breath at night Y ___ N ____ Shortness of Breath on exertion Y ___ N ____ If Female, could you be preg? Y ___ N ____ Number of live births_______________________ Number of pregnancies ____________________ Date of last mammogram ___________________ Date of date of menses (period)______________ ASSIGNMENT AND RELEASE
I, the undersigned, have insurance coverage with _________________________________________ and assign directly to Kami Parsa, M.D., Professional
Corporation, all Medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or
not paid by insurance. If the nature of the disability be such that it is not covered by insurance, I will be responsible to the doctor for payment of the entire bill. 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. _________________________________________________________ _________________________________________________________

Source: http://www.oculoplastic.info/pdf/intake-paperwk.pdf

Microsoft word - grippe

Influenza – Grippe Die Influenza, deutsch »echte Grippe«, wird durch Influenzaviren verursacht. Im Volksmund wird die Bezeichnung „Grippe“ häufig für grippale Infekte verwendet, bei denen es sich aber um verschiedene, in der Regel deutlich harmloser verlaufende Viruserkrankungen als die »echte Grippe« handelt. Die Influenzaviren gehören zur Familie der Orthomyxoviridae. Syst

Mdp322 1319.1329

Thresholds for therapies: highlights of the St GallenInternational Expert Consensus on the Primary Therapyof Early Breast Cancer 2009A. Goldhirsch1,2*, J. N. Ingle3, R. D. Gelber4, A. S. Coates5, B. Thu¨rlimann6, H.-J. Senn7& Panel members 1International Breast Cancer Study Group, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; 2European Institute of Oncology, Milan, It

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