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BEVERLY A. FISCHER, M.D., Medical Director
Plastic, Reconstructive, and Cosmetic Surgery The following information is very important to your health. Please take the time to fully and
completely fill out this important information. We are counting on you.
Today’s Date:__________

Patient’s Name:_______________________________________________________________________________


Address:____________________________________________________________________________________

___________________________________________________________________________________________ Home ___________________________________________________________________________________________ Marital Status Occupation:_______________________________
Employer:________________________________________
___________________________________________________________________________________________ Employer’s Address
Emergency Contact Person: ____________________ Relationship: _______________ Phone #: _______________
___________________________________________________________________________________________
Address
___________________________________________________________________________________________ Work
How were you referred to our office?
____ A friend* ____ Radio ____ Billboard ____ Your Doctor* _____ Emergency Room ____ Newspaper* ____ One Book ____ Bell Atlantic Yellow pages ____ Internet Name of referring person/doctor/newspaper________________________________________ Address of referring person/doctor/newspaper______________________________________ Please tell us why you chose Dr. Fischer to be your physician__________________________________
PAST MEDICAL HISTORY
Health:_____ Good ____ Fair _____ Poor If not good, please explain:___________________________________
___________________________________________________________________________________________
DO YOU SMOKE? ____ No ____ Yes

PREVIOUS SURGERY:
Operation Year
___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Complications after surgery:______________________________________________________________________ PRESENT HISTORY
of Personal Physician___________________________________
Address of Personal Physician_________________________________________________ Phone#_____________
Please list any serious illnesses:____________________________________________________________________
Medications: List current medications including blood thinner, aspirin, Bufferin, Advil, birth control pills, diuretics, blood pressure
or heart medications, steroids, tranquilizers, hormones, etc._______________________________________

ALLERGIES TO MEDICATIONS?_
_____________________________________________________________
ARE YOU ALLERGIC TO LATEX?_______________________________________________________
USE OF HERBAL DRUGS OR THERAPIES?________________________________________________
USE OF DIET MEDICATIONS?_________________________________________________________

Have you taken steroids, i.e. prednisone, cortisone, medrol, etc. in the past 12 months?______
Have you ever had cold sores or fever blisters?_______
Have you ever had…? (Please check those that apply): mental or nervous disease____ high blood pressure____
lung disease____ Keloids____ glaucoma____ heart disease____ kidney disease____ bruise/bleed easily____
cataracts____ Diabetes____ asthma____ allergies to adhesive tape____
RELEASE OF INFORMATION:
I certify that the information I have reported with regard to my insurance coverage is correct. I authorize the necessary release
of any information, including medical information to my insurance carrier.
Signed:_________________________________________ Date:_________________________
PRESENT PROBLEM:

IS THIS TO BE SUBMITTED TO INSURANCE COMPANY______ Yes ______ No
Problem for which you are seeking plastic surgery:______________________________________________________
Area(s) of the body____________________________________________________________________________
Is this related to an injury/accident? ___________
if Yes, date injury occurred________________ Have you consulted other doctors about this?________ If Yes, who________________________________________
Questions to discuss:___________________________________________________________________________
THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY BELIEF.____________________________
INSURANCE INFORMATION:
Primary Insurance Company________________________________ Policy
Policy Holder’s S.S.#________________________ Policy Identification # _________________________
Responsible Party:____ Patient ____ Spouse ____ Parent PLEASE PROVIDE INSURANCE CARD & DRIVERS LICENSE.
I authorize release of my medical records to the insurance company or responsible party for billing purposes. I authorize the
insurance company or responsible party to pay directly to the Advanced Center for Plastic Surgery. For and in consideration of
services rendered, the undersigned jointly and severally obligates themselves for the payment of all services rendered by Dr. Fischer
and her staff. The undersigned hereby acknowledge that I/we are financially responsible for any health insurance deductible,
coinsurance, or failure for any reason of any insurance carrier to pay Dr. Fischer’s charges, which I/we are due and rendered. In the
event the patient’s account is referred for collection, the undersigned agrees to pay and be responsible for all such medical charges
together with all court costs, private process fees, collection costs and attorney’s fees in the amount of 1/3 of the balance, which
sum the undersigned expressly agrees is reasonable. This assignment will remain in effect unless revoked by me in writing. A
photocopy of this is to be considered valid as the original.

Signature:___________________________________________ Date:____________________________

FINANCIAL POLICY
1. The fee for the initial cosmetic consultation is $100.00, payable at the time of service. This fee includes a second consultation within 60 days, if needed. The fee for the initial insurance consultation ranges between $100.00 - $250.00 depending on length and focus of visit. 2. An estimate of the surgical fee will be provided at the time of consultation. This estimate does not include expenses which the patient may incur for a "History and Physical" examination, blood tests, and prescriptions. A 10% deposit is required when the surgery date is scheduled.
3. Final payment for all cosmetic surgeries must be made at least three (3) weeks prior to the scheduled surgery
date. Fees are fully refundable for cancellations made no later than three (3) weeks prior to the date of
surgery.
A 50% refund will be made for surgeries which are cancelled 14-20 days prior to surgery. There will be
no refunds for cancellations within 13 days of the scheduled surgery. A surgery which has been rescheduled and
subsequently cancelled again is subject to no greater than a 50% refund.
4. The patient is solely responsible for the entire fee, regardless of the source of payment. In the case of insurance-covered procedures, the patient is responsible for any co-payments and/or deductibles. On rare occasions a surgery may include a procedure, which is covered by insurance and one, which is not. In these cases, there may be two consultation and two anesthesia charges. If the insurance company pays these, the patient will be responsible for any co-payments. 5. All post-operative visits relating to the original procedure are included in the surgical fee for up to one (1) year. Consultations for unrelated procedures will be billed separately. 6. There will be a reduced surgeon's fee assessed for cosmetic re-operations involving minor revisions, which are performed within twelve (12) months of the original date of surgery. The patient, however, is fully responsible
for the operating room facility fee, anesthesia fee, and all supplies…minimum fee = $1650.00.
***Initials__________***
7. There will be a $30.00 fee for any check returned to the practice unpaid. 8. Exceptions to this policy will be considered on a case by case basis and will be at the sole discretion of the 9. There will be a $50.00 fee billed to new patients for missed consultation appointments without prior 48 hours
Signature:___________________________________________
Date:________________________________

CONSENT FOR PHOTOGRAPHS

I hereby authorize Dr. Fischer or any staff to take before and after photos for surgical purposes only.
Signature:___________________________________________
Date:________________________________

Source: http://www.beverlyfischer.com/App_Themes/t17/PatientInfoSheet.pdf

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