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