New Patient Form

Print Blank New Patient Form

Patient Name* (Last, First, Middle Initial):


Street Address:

Street Address 2:

City: State: Zip:

Email:*

Home Phone: Mobile Phone:

Sex: MaleFemale
SSN: Birthdate: Age:*

Marital Status:
MarriedDivorcedSingleWidowedPartnered
If Married, Spouse's Name:
Emergency Contact
Name: Phone:
Employed YesNoRetired
Occupation Employer:
May we call you at work: YesNo Work Phone:

Smoking Status Current Every Day SmokerCurrent Some Day SmokerFormer SmokerNever SmokerUnknown

Health Insurance:

Primary Health Insurance Company:

Insured ID #

Policyholder’s Name:Group ID#:

Policyholder’s DOB: SSN#: Relationship:

Secondary Health Insurance Company:

Insured ID #

Policyholder’s Name:Group ID#:

Policyholder’s DOB: SSN#: Relationship:

The American Recovery & Reinvestment Act of 2009 requires we gather additional information from you about your background. Thank you for answering the following three questions.
1. Race:
AsianBlack, African AmericanAmerican Indian/Alaska NativeWhiteHispanic/Latino NativeHawaiian/Pacific IslanderDeclined
2. Primary Language: EnglishSpanishOther (Specify Below)
3. Ethnicity: Hispanic/LatinoNon-Hispanic/LatinoDeclined
If the patient is a minor, please complete:
Mother’s Name Date of Birth: Phone:

Father’s Name Date of Birth: Phone:
The child lives with MotherFatherBoth ParentsOther (If other, please specify )

Referring Physician
Name Specialty
Address

Phone # Fax #

Primary Physician
Name Specialty
Address

Phone # Fax #

Other Physician (Regularly seen for continual care)
Name Specialty
Address

Phone # Fax #
Best way to reach you with test results:
Home PhoneCell PhoneEmail
In the case of favorable test results, may we leave a message on your answering machine? YesNo
I give permission for Dr. Eric Baylin and/or Dr. Javier Servat and their staff to discuss my health status with the following people:
Name: Phone :Relationship:
Name: Phone :Relationship:
Name: Phone :Relationship:
Enter your name to sign this form electronically:

Health Information

Confidential Record: Information contained here will not be released unless you have authorized us to do so.

Height: Weight:
Reason for upcoming visit:
List previous surgeries including the procedure, date and surgeon:

List all serious illnesses and/or accidents:

Medical History

Please check below if you have, or have had any of these medical conditions:

Alzheimer’s/significant memory lossHay Fever/AllergiesPacemakerArthritisHemophilia/ Excessive BleedingPneumoniaAsthmaHepatitisSinus Infections/ProblemsCancer (enter type below)Herpes Simplex/Fever BlistersSleep ApneaCongestive Heart FailureHigh Blood Pressure/HypertensionCPAP MachineDepressionHIV or AIDSStrokeDiabetesKidney DiseaseThyroid DiseaseEpilepsy/SeizuresInfections (enter type below)TuberculosisFibromyalgiaOther (please enter below)

Type/Additional Information
If Infections: MRSA? YesNo

Do you have bleeding/bruising problems? YesNo
If yes, describe:
Do you have problems with scarring?YesNo
If yes, describe:
Do you have a history of problems with anesthesia? YesNo
If yes, describe:
Do you use recreational drugs? YesNo
If yes, describe:
Do you dip or chew tobacco?YesNo
If yes, how much per day:
Do you drink alcohol?YesNo
If yes, how much?
If yes, how often?

The above information is accurate and complete to the best of my knowledge.
Enter your name to sign this form

Name of Pharmacy

Location: Phone:
Do you have any known drug allergies? YesNo
Please list any allergies to Drugs, OTC Medicine, etc., including known side effects.

List the name of all medications, vitamins and supplements you are presently taking or have taken within the last month. Please include the name of the drug, dosage and frequency.

Financial Policy & Insurance Agreement

Please read the Financial Policy and Insurance Agreement below, then check the checkbox at the bottom to indicate you have read, understood and agreed to the insurance and financial policies:

1. Your insurance policy is a contract between you, your employer (if applicable), and the insurance company. We are not a party to that contract. Our relationship is with you, not your insurance company. We will not become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance and “usual and customary” charges. As your medical provider, we will only supply factual information to facilitate claim processing.
2. Your co-pay amount (for a medical specialist) set by your insurance company is due at the time of service. You are ultimately responsible for payment of all charges received in our office, including but not limited to insurance deductibles, lab fees, out-of-pocket expenses, co-insurance amounts or any outstanding balances not covered by health insurance.
3. It is your responsibility to provide us with your current health insurance information, as well as your correct address and telephone number at each visit.
4. It is your responsibility to confirm with your insurance carrier that Dr. Baylin is in your network prior to your appointment. If you choose to see him out of network, you will be responsible for payment in full.
5. An Administrative Services Fee ranging from $10-$50 per request will be assessed for the completion or compilation of paperwork for Work Release, Return to Work, FMLA or cases involving legal counsel. This fee will be determined by OPSGA dependent on the clerical time involved or the frequency of requests.
6. We request account balances be paid in full when the sum is $200 or less. For outstanding balances exceeding $200, a minimum of 20% of the amount owed must be paid promptly.
7. A fee of $25 will be added to your account for any check dishonored by your bank. Returned checks of $500 or more will be assessed a fee equal to 5% of the amount of the check.
8. Accounts turned over to a collection agency will be assessed a $25 fee; you will be responsible for all legal fees.
9. Scheduling a surgery requires extensive work from our surgical & insurance coordinators and the surgery facility. Because of this, it is imperative that you keep your surgery appointment once it is scheduled. You will never be penalized for canceling a surgery due to failed insurance coverage, or if your primary care physician will not grant you surgical clearance, but please take special note of these policies:

  • Within 30 days of your surgery, if you reschedule your surgery date, you will be charged a $100 fee. This fee must be paid before a new date will be scheduled.
  • Within 30days of your surgery, if you cancel your surgery date, you will be charged a $250 fee. This fee must be paid before a new date will be scheduled.
  • The rescheduling and cancellation fees are not covered by your insurance.
  • I have read, understood and agreed to the insurance and financial policies stated above. I agree that I have had the opportunity to discuss any questions or concerns regarding the above with one of the Insurance Specialists for the practice.

    Type your name to indicate Signature of Patient or Legal Guardian:

    If Patient unable to sign, please enter the reason:

    Patient Consent for Use/Disclosure of Health Care Information

    With my consent, Oculofacial Plastic Surgeons of Georgia, LLC, (OPSGA) may use and disclose my protected healthcare information to carry out treatment, payment and healthcare operations. I further understand OPSGA may need to disclose protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax or email. I understand OPSGA originates and maintains paper and electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.
    For a more complete description of such uses and disclosures, I will refer to OPSGA’s Notice of Privacy Practices. This document is available to review on OPSGA’s website or may be obtained by written request to OPSGA’s Johns Creek office. OPSGA reserves the right to revise its Notice of Privacy Practices at any time.
    I have the right to request that OPSGA restrict its use or disclosure of my protected health information. While OPSGA is not required to agree to my requested restrictions, if it does, it is bound by this agreement.
    I may revoke my consent in writing, except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, due to the restrictions on disclosure of healthcare information and its effect on the ability to perform diagnosis and treatment, OPSGA may decline to provide treatment to me.

    My signature below indicates I have been given the opportunity to review OPSGA’s Notice of Privacy Practices and I am consenting to OPSGA’s use and disclosure of my protected healthcare information.

    Type your name to indicate Signature of Patient or Legal Guardian:

    If Patient unable to sign, please enter the reason:

    Photo Consent:

    ​I consent and authorize the release of my photographs to Oculofacial Plastic Surgeons of GA LLC (a.k.a OPSGA) for educational use in any and all of its printed and digital publications. I waive the right to inspect of approve the finished product, wherein my photo appears in print or digital format. I acknowledge this permission is voluntary; I will receive no financial compensation. This permission is effective indefinitely, or until I give written notice breaking this Agreement.

    Type your name to indicate Signature of Patient or Legal Guardian: