New Patient Form New Patient Form Step 1 of 3 33% Name* First Last Who may we thank for referring you to us?What is your date of birth (DOB)?* MM DD YYYY What is your gender?* Male Female What is your cell phone number?*What type of message can we leave on your cell phone?* Detailed message Doctor's name and number Do not leave a message If you would like to receive reminders via text message, please select your wireless carrier: AT&T Bellsouth Boost Mobile C-Spire Cricket Nextel Sprint Straight Talk T-Mobile TracFone Verizon Virgin Mobile What is your alternate number?What type of message can we leave at your alternate number? Detailed message Doctor's name and number Do not leave a message What is your email address?* Would you like to be notified of special offers and promotions?* Yes No What is your address?* Street Address City State / Province / Region ZIP / Postal Code Who is your emergency contact?* First Last What is the phone number of your emergency contact?*What is the reason for your visit?* Consultation Follow-Up Injectable Laser Treatment Skincare/Facial Other Are you interested in any of the following services? Dermal Fillers Botox Laser Hair Removal Laser Tattoo Removal Facials or Peels Skincare Consultation Collagen Induction Therapy/Microchanneling Nonsurgical Facelift Breast Augmentation Liposuction CombiTuck Neck Lift Blepharoplasty (Eyelid Lift) Spider or Varicose Vein Treatments Bioidentical Hormone Replacement Therapy (BHRT) What is the phone number of your preferred pharmacy? Have you ever had any of the following? Abdominal pain Acne Anemia/blood diseases Anorexia or bulimia Arthritis or gout Asthma or COPD Back problems Bronchitis Cancer Crohn's Disease Depression Diabetes Dizzy/fainting spells Eczema Epilepsy or seizures GERD Hay fever Heart disease Hepatitis High blood pressure High cholesterol Intestinal trouble Kidney stones/cysts/failure Migraine headaches Phlebitis Pneumonia Psoriasis Psychosis Rheumatic fever Sexually transmitted disease Sleep apnea Thyroid problems Ulcers Warts Are you allergic to any of the following? Alcohol Almonds Antihistamines Aspirin Bees/wasps/hornets Black mold Brazil nuts Cheese Chlorine bleach Codeine Corticosteroids Cow's milk Decongestants Dust mites Eggs Fish Hazelnuts Ibuprofen Latex Olive oil Peanuts Penicillin Pet dander Poison ivy/oak/sumac Pollen Ragweed Sesame Shellfish Soy Sulfa drugs Sunflower seeds Tetracycline Walnuts Wheat Other Please explain if you selected "other"Please list any medications you are currently taking:*Has anyone in your family ever had a history of any of the following? Alcoholism Anemia/blood diseases Arthritis or gout Asthma or COPD Birth defects Blood clotting disorder Cancer Depression Diabetes Glaucoma Heart disease High blood pressure High cholesterol Stroke Sudden death (before age 50) How often do you consume alcohol?* Never Rarely Occasionally Frequently How often do you consume caffeine?* Never Rarely Occasionally Frequently How often do you use tobacco products?* Never Rarely Occasionally Frequently Are you pregnant or breastfeeding?* Yes No HIPAA I. AUTHORIZATION FOR TREATMENT AND ASSIGNMENT OF BENEFITS I do hereby consent to medical evaluation and treatment by my physician, physician representatives and technicians. In the case of diagnostic studies, laboratory tests, psychology and physical therapy treatment, as prescribed by my physician, I hereby consent to treatment by the technologist, physician and mid-level providers (and their representatives). I do hereby authorize Germantown Aesthetics (GA) to release to any third party payer (such as an insurance company or government agency) any necessary medical and/or psychiatric information and records concerning diagnosis and treatment when requested by such a third party for use in determining payment for medical services. I do hereby authorize payment directly to any GA Provider examining and/or treating me, from any group or individual medical benefits herein specified and otherwise payable to me for their services. I certify that the information given to me in applying for payment under the Title XVIII/XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to Health Care Financing Administration, Social Security Administration/Division of Family Services, Blue Cross Blue Shield of Tennessee, Medicare or its intermediaries or any other carriers any additional information needed for this or a related Medicare claim. I hereby certify that all insurance pertaining to treatment shall be assigned to the GA provider treating me. I permit a copy of these authorizations and assignments to be used in place of the original, which is on file with GA. I understand this is a lifetime authorization remaining in effect until revoked by me in writing. I agree that payment for professional services is due and payable when services are rendered. I agree that should the amount of the insurance benefits be insufficient to cover the amount of the claim, I will be responsible for payment of the balance of my account for any professional services rendered. I agree to be responsible for any co-payment and/or deductible associated with my insurance policy. I understand a $10.00 billing fee will be charged for co-pays and deductibles not paid at time of service. I also understand GA will help in billing my insurance company for payment but it is my responsibility to follow-up on any claim submitted if any payment is not received in a reasonable amount of time. A finance charge of 1.5% periodic will be added to all patient account balances left outstanding for more than 30 days. I agree that I will be responsible for any collection fees if it becomes necessary to send my account for collections. I agree that I will be responsible for any fees for returned checks. II. USE AND DISCLOSURE OF HEALTH INFORMATION Pursuant to the requirements found in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the following is offered for your information and consent. Please be aware that it is this corporation’s policy to require your reading and signing this consent form prior to the provision of treatment or any other medical services. If you have any questions, please ask for the Privacy Officer of this corporation. I do hereby consent to the use and disclosure of my individually identifiable health information (“Health Information”) by Germantown Aesthetics (GA) and its Professional Providers (“Provider”) for the purposes of providing treatment to me, receiving payment from responsible parties for health care services rendered by the Provider, and/or engaging in health care operations, such as office management, credentialing, case management, and quality assessment. This authorizes the release of my Health Information or copies of such to be transferred to myself and/or any physician that I am referred to by a GA Provider. I understand that Provider’s Notice of Privacy Practices (“Notice”) describes in more detail the types of uses of disclosures of Health Information involved in treatment, payment or health care operations, and that I have a right to request and review such Notice prior to signing this consent. I understand that the Provider has reserved the right to change its privacy practices as described in the Notice. In the event of any change in the Provider’s privacy practices, Provider will revise the Notice. I understand that I can obtain a copy of the revised Notice by writing to Provider. I understand that if I choose to not sign this consent, Provider may withhold medical services, other than emergency services. I understand that I have the right to request a restriction (ask for and see Patient Authorization to Use/Disclose Health Information) on Provider’s use or disclosure of any and/or all Health Information to any and/or all locations, entities, or persons (including family members I wish to have or not have access to my Health Information). I further understand that Provider is not obligated to agree to my request. However, if Provider does agree to my request, the agreement will become binding. I understand that I have the right to revoke this consent, in writing, at any time, except to the extent that Provider has relied on this consent, and that any revocation will become effective on the date it has been received by Provider and will apply to uses and disclosures of the Health Information after the date of receipt. Do you accept the HIPAA agreement?* I accept the agreement I decline the agreement MEDICAL PROFESSIONAL LIABILITY ARBITRATION AND PRIVACY AGREEMENT This arbitration document is meant to preserve your rights AND maintain the responsibility that the staff Physicians of Germantown Aesthetics; div of MVAG, Inc., have for you. You are invited to discuss any portion of this agreement with any of our staff or an attorney before your surgery.In consideration of the agreement of: I. Germantown Aesthetics; div of MVAG, Inc. II. The Surgeons of Germantown Aesthetics; div of MVAG, Inc. III. The Medical Director of Germantown Aesthetics; div of MVAG, Inc. IV. The staff under contract with Germantown Aesthetics; div of MVAG, Inc. (Including those individuals under lease service agreement from any third party staffing entity): herein called the “Providers,” to render certain medical and surgical services for hereinafter named patient, the providers and patient do hereby agree as follows: (1) It is understood that any dispute as to medical malpractice, that is as to whether any medical service rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the laws of the State of Tennessee, TN Code Ann. § 29-5-302 (1980), and not by a lawsuit or resort to court process except as the law of the State of Tennessee provides for judicial review of arbitration proceeding, both parties to this contract, by entering into it, are giving up their right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. (2) In the event of any claim, demand, controversy, civil action or dispute, including but not limited to personal injury, malpractice, or any tort, whether brought in tort, contract or otherwise, by Patient, his dependents, whether or not minors, heirs at law, or person representatives, against Doctor or any of Doctor’s officers, directors, shareholders, agents, representatives, employees, successors in interest, assigns, staff physicians or associates agreeing in writing to be bound by this arbitration provisions of the agreement (“Affiliates”) THE SOLE METHOD FOR RESOLVING SUCH DISPUTE SHALL BE BY BINDING ARBITRATION ADMINISTERED BY THE AMERICAN ARBITRATION ASSOCIATION in accordance with the Commercial Arbitration Rules of the American Arbitration Association(AAA). The parties hereby agree that they shall submit their controversy to a neutral arbitrator provided by the AAA, who shall decide the controversy based on the evidence presented. The arbitrator will be agreed upon by mutual consent of the parties. It is agreed that all parties relevant to a full and complete settlement of any dispute subject to this agreement may be interviewed or joined. The parties further agree that the commercial arbitration rules of the American Arbitration Association (AAA) shall govern all arbitration conducted pursuant to this Arbitration Agreement. (3) The prevailing party in any arbitration pursuant to this agreement shall be all cost, including reasonable attorneys’ fees and the arbitrators’ fees, in prosecuting or defending the claim in arbitration, but not to exceed $2,000.00 in amount. Furthermore, if any action is initiated or undertaken to set aside or otherwise attack this arbitration agreement or award, or to compel arbitration, the prevailing party in the court action shall be entitled to all costs of such action, including reasonable attorney’s fees as may be fixed by the court. (4) Any party initiating arbitration under this agreement shall file with his/her petition a bond or cash surety in the amount equal to One Thousand Dollars ($1,000.00), which shall provide security for attorney’s fees and costs in the event that the moving party should not prevail. (5) In the event that any provision of this agreement shall be void or unenforceable for any reason whatsoever, then such provision or provisions shall be stricken and shall be of no force and effect. The remaining provisions of this agreement, however, shall continue in full force and effect, and to the extent required, shall be modified to preserve their validity. (6) This agreement shall not limit the ability of the physician, in the exercise of his professional judgment, to refer the patient to other physicians or to decline further medical treatment to the patient. (7) Further, it is understood that a patient’s medical information will be considered private, and will only be released after the presentation of a signed patient request. Even though HIPAA statues do allow for covered medical entities to release information to other covered entities, the privacy standard of the Providers is stricter, and private information will NOT be released to other HIPAA entities without the permission of the patient. Likewise, the patient agrees to protect the trade and reputation of the Providers by extending a similar level of consideration. Only permissible avenue of dispute resolution is the binding arbitration process, and the patient agrees to make no publications or statements - public or private, written or oral - which would harm the trade of the Providers. A violation will result in damages of no less than $20,000.00. By statute, the results of any Arbitration finding may become a matter of public record. (8) This agreement shall be construed in accordance with and governed by the law of the State of Tennessee. THIS IS A BINDING LEGAL DOCUMENT, WHICH MAY HAVE AN IMPORTANT EFFECT ON YOUR LEGAL RIGHTS. THIS AGREEMENT PROVIDES THAT ALL MEDICAL CONTROVERSIES SHALL BE DECIDED BY AN ABITRATOR AGREED UPON MUTUALLY. CONSULT YOUR ATTORNEY ON ANY QUESTIONS YOU MAY HAVE. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE ONE (1) OF THIS CONTRACTDo you accept the arbitration agreement?* I accept the agreement I decline the agreement By typing your name and today's date below, you indicate that you: • have read and agree to the HIPAA and Arbitration Agreements • have received a copy of the HIPAA and Arbitration Agreements • have provided truthful information to Germantown Aesthetics You may download a copy of these agreements for your records: HIPAA ARBITRATION AGREEMENTFirst and last name:*Today's Date:* Date Format: MM slash DD slash YYYY