PS New Patient English Web Form (TBU)

New Patient Questionnaire

First Name *
Last Name *

Did you use the same First/Last Name as with previous online or front office communication?

SS#:

Date of last surgery *

How long after surgery did you notice change/problem? *

Onset date of your change/problem *

Have you had this problem before?

YesNo

What types of changes occurred?( Please check all that apply to you)

Pain

Scar

Position/Shape

Firm

Other

If other, please explain

Patients medical history ( Please check all that apply):

Diabetes

Cancer

Heart Disease/Angina

Allergies ( Medication)

Are you allergic to Latex?

Balance Disorders

Pacemaker/Implantable Defibrillator

Hypertension/High Blood Presure

Shortness of Breath/Asthma

Stroke

Osteoporosis/Rib/Spine Fractures in past

If applicable, are you pregnant?

Other medical conditions

After / Before Surgery do/ did you?

Have excessive black/blue marks

YesNo

Become pregnant or breastfeed

YesNo

Smoke/Use tobacco

YesNo

Have infection in breast/incision

YesNo

Sustain trauma or injury to breast

YesNo

Returned to gym before 6 weeks

YesNo

Have any dental cleaning/work

YesNo

Have seroma/hematoma drained

YesNo

Type of Implant (ex: Saline, Silicone) *

Implant Above/Below Muscle *

Implant Size (cc's) *

Other Issues you feel relate to start of condition:

What are your goals for the Aspen Treatment? *

How are you limited in your day-to-day activity

Cultural/Religious- Any customs or religious beliefs or wishes that might affect care?

Occupation

Do you exercise regularly?

YesNo

If yes, how often/ how long?

Do you have difficulty sleeping because of your problem?

YesNo

What type of exercise?

How do you best learn?

PicturesReadingListeningDemostration

Please list all current medications you are taking

Chronologically list dates and types of surgeries you have had of any kind related to this condition.

Very 1st surgery *

2nd surgery date

3rd surgery date

4th surgery date

5th surgery date

Baker grade as diagnosed by your plastic surgeon. (if unsure ask surgeon for this grade or simply list your best guess)

Baker grade *

On a scale from 0-10 (10 being worst hardness and 0 normal softness) what number would you say your breast implant firmness is now?

Hardness scale 0-10 *

On a scale from 0-10 (10 being worst shape/position and 0 normal shape/position) what degree would you say your breast(s) is now?

Shape/position scale 0-10 *

PAIN BEHAVIOR: Please CHECK any items below that apply to you.

Aching

Throbbing

Sharp

Firmness

Electric/Shooting

Tightness

On/Off

Your pain is worse: Please CHECK any items below that apply to you.

Lifting Arm

Exercising

Standing

Lying on tummy

Lying on side

In AM

As day progresses

In PM

At rest

On the move

Write the areas where you feel your pain or where your problem area is .

Area *

What is the level of your pain today?

Pain scale 0-10 *

Patient intake form

Referred by:

Patient Name *

Home Address *
City *
State *
Zip Code *
Country *

Phone* *

Email *

Did you use the same email and phone number as with previous online or front office communication? *

Date of Birth *

Employer:

Employer Phone Number:

Spouse's Employer:

Reffering Physician

Reffering Physician Phone Number:

Primary Physician:

Primary Physician Office Number

Emergency Name/ Number *

AUTHORIZATION AND CONSENT FOR TREATMENT

1. I, the undersigned, acting on my behalf or as the legally authorized representative of patient stated below, do consent for treatment provided by ASPEN REHAB TECHNOLOGIES, LLC EIN# 30-0532407. I agree to treatment by its employees, independent contractors, and business associates, which relate to care and treatment as designated.

2. I understand and acknowledge that insurance benefits are not covered for cosmetic/reconstructive treatment and that insurance claims are not filed. I understand and acknowledge I am fully responsible for payment and any charges for care and services provided by Aspen Rehab Technologies, LLC. Any reversed credit card charges against Aspen Rehab Technologies, LLC will have a 40% additional fee added to the amount owed for legal services to collect. I understand and acknowledge that Treatments are NON- REFUNDABLE. The payment for treatment is due on the second visit in full. We accept Cash, Visa, Master Card, Discover, and Checks (return checks are subject to a fee of $35).

3. I understand that Aspen Rehab Technologies, LLC may share my medical information, without my consent or express authorization, to my physician, providers, payers, business associates, and other entities for the purpose of treatment, payment, or healthcare services. My signature below authorizes this sharing of my information and that no information will be shared, used, disseminated, and collected for any other purposes than previously described.

4. I understand that Aspen Rehab Technologies, LLC will provide therapy services that with diagnosis and treatment may involve risk and injury. I acknowledge that no guarantees have been made to me as a result of examination, care, or treatment. I acknowledge that I have the right to request an explanation of risks and benefits from services provided.

5. I acknowledge that therapeutic treatment for post-cosmetic surgery may involve tissue manipulation of the affected areas, which may include breasts, buttocks, or abdominal region. I understand that all efforts will be made to ensure a female therapist will provide treatment; but that a male therapist may at times provide an initial evaluation and periodic follow-up treatment. I understand that in the event a male therapist is providing treatment, a female staff member will be present throughout the session.

6. I understand that Aspen Rehab Technologies, LLC is not legally responsible for the acts and omissions of its independent contractors.

7. I understand that Aspen Rehab Technologies, LLC Cancellation Policy requires 24 hours notice or a $40 charge may be imposed. This also applies when I arrive at least 15 minutes late to an appointment. I also understand that not showing for appointments without cancellation on two (2) or more occasions may result in being discharged from therapy services.

8. I hereby acknowledge that I have received a copy of Aspen Rehab Technologies, LLC NOTICE OF PRIVACY PRACTICES for my review, prior to receiving initial services from Aspen Rehab Technologies, LLC either now or in the past.

* I have read and accept the Authorization and Consent for Treatment

Consent to Take or Use Photographs

The Undersigned does hereby authorize ASPEN REHABILITATION TECHNOLOGIES, LLC to use my photographs or permit other persons to take my photograph while a patient, and agrees that they may use or permit other persons to use the negatives or prints prepared there from for such purposes as evaluation of progress, treatment, research, and in such manner as may be deemed necessary. This consent is expressly intended to release from liability all of the above named facility's personnel and consultants.

Printed Name (consent signature): *

Authorization to Release Medical Information/HIPAA Compliance

I authorize the release of the following protected health information:

Name of Plastic Surgeon

Treatment Information

By signing this form, I am authorizing the use or disclosure of protected health information as indicated above.
I may refuse to sign this authorization, which will not affect my treatment or payment for healthcare.
I may revoke this authorization at any time before the information I have requested is released by providing written notice of revocation as specified in the Notice of Privacy Practices.
If the receiving party is not subject to medical records privacy laws, the information may be re-disclosed by the recipient and may no longer be protected by federal or state law. Aspen Rehabilitation shall not be held liable for any consequences resulting from re-disclosure.
If the information to be release contains any information about HIV/AIDS and additional HIPAA release of medical Information for will be requested.
Alcohol or substance abuse, mental health or psychiatry notes may have additional compliance requirements that must be met before the information can be released.
A copy of this signed form will be provided to me.
Aspen Rehabilitation may charge and administrative fee to cover cost of labor, copying, and postage. The physician’s office will inform me of any charges and arrange for payment.

This Authorization Expires one year after signed).

I have read and authorize to Release Medical Information /HIPPA Compliance *