Deirdre Leake, M.D.
Cheron Haggard, L.E. Amanda Alton, L.E.
First Middle Last
Street / Mailing City State Zip
Birth date_______________________ Age________ Sex ________ Social Security # _______________________
Home Phone ________________________________ Work Phone ______________________________________
E-mail _______________________________________ Cell Phone _____________________________________
Employer __________________________________ Occupation _______________________________________
Spouse Name ____________________________________ Work Phone ________________________________
How did you hear about Dr. Leake? _______________________________________________________________
May we send you information via mail or email? _____________________________________
What area(s) of the face are you interested in having cosmetically or functionally improved? ___________________
Family Physician: _____________________________________________________________________________
Phone Number: _____________________________________
When was your last physical exam? _______________________________________________________________
List any medical conditions for which you are presently being treated or have been treated: ___________________
Do you eat a well balanced diet? _________________________________________________________________
List any surgical history and any complications including dates and anesthesia: _____________________________
Have you had cosmetic procedures or surgery? _____________________________________________________
When & What Type _________________________________________________________________________
1750 Tree Blvd., Suite 10
St. Augustine, FL 32084
List any medications, vitamins, and over-the counter drugs you are presently taking and dosages: _____________
Have you taken any steroid preparations over the past year? ___________________________________________
Have you taken any accutane therapy over the past 18 months? ________________________________________
Please indicate the products you use (Cleanser, toner, moisturizer, etc.): __________________________________
Have you ever used any of the following?
Retina A ____________________ When? _________________ Reaction? ______________________________
Glycolic Acid ________________ When? _________________ Reaction? ______________________________
Other Acne medications _____________ When? _____________ Reaction? _____________________________
Allergies (VERY IMPORTANT QUESTION, PLEASE ANSWER EVEN IF IT IS NONE)
List any drug allergies (including local anesthetics, over the counter medications, tape or latex): ________________
Do you smoke? Y / N Packs per day/ years? _______________ Quit/ When? _________________________
Do you drink more than two drinks a day? __________________________________________________________
Review of Systems:
Eye Oral cavity/ Oropharynx
Visual loss R / L Difficult/ painful swallowing
Dry eyes R / L Hoarseness
Itching or irritation of eyes Persistent sore throat
Crossed or lazy eyes R / L
Cornea problems Ears
Thyroid eye disease Ear Drainage R / L
Wear glasses or contacts Ringing R / L
Blurred or double vision R / L Hearing loss R / L
Previous eye or eyelid surgery Vertigo
If yes, what type of surgery?
Ear pain R / L
Shortness of breath
Neurological Chronic lung disease
Convulsions Frequent cough
Memory loss Chest pain
1750 Tree Blvd., Suite 10
St. Augustine, FL 32084
Bleeding disorder: self/family Lumps in neck
Blood transfusions Thyroid problems
Blood clots Diabetes
Kidney or bladder disorders Mitral valve prolapse
Chronic urinary tract infections Congenital heart disease
Pain or problem passing urine Heart murmur/ palpitations
Burning or bleeding while urinating Hypertension
Do you tan (artificially or naturally)? Endocrine/GI
Do you have or ever had eczema or Heat/cold intolerance
Dermatitis? Weight loss / gain How Much? _______
Do you have hyper pigmentation from the Bleeding
Sun and/or during pregnancy? Diarrhea
Persistent skin lesions Stomach problems/ulcer
Irritation to face or neck History of thyroid problems
Facial paralysis or weakness Stomach pain
Facial skin problems Nausea/vomiting
History of cold sores
Skin rashes or ulcers Nose
Any unusual scarring or keloid formation Post nasal drip
Previous face of neck surgery Previous injury to nose
If yes, what type of surgery? Difficulty breathing through the nose
__________________________ Nasal allergies
__________________________ Nose bleeds
Other Previous nasal or sinus surgery
Communicable disease – such as tuberculosis If yes, what type of surgery?
Liver disorder including hepatitis or cirrhosis ______________________________
Persistent snoring ______________________________
Autoimmune disease (lupus, rheumatoid, Psychiatric
Arthritis, etc) Have you ever received psychiatric
Spinal or back disorders treatment? Y / N
Are you pregnant or lactating? If yes, were you hospitalized? Y / N
Do you have claustrophobia?
Physical Exam Has there been any recent crisis in your life?
Height ___________ Weight__________ Have you ever been treated for drug
or alcohol dependency?
1750 Tree Blvd., Suite 10
St. Augustine, FL 32084
INSURANCE INFORMATION (cosmetic patients, please read)
Your insurance card must be presented at the time of your initial visit. We realize that these services are not covered by
insurance but, if available we like to keep your insurance information on file. A great many of our cosmetic patients
eventually become insurance patients and having the card expedites billing and payment and also puts the responsibility
for payment on your insurance company instead of you.
Whenever applicable, we will collect your portion of your charges at the time of your visit.
24 hour advanced notice is required for cancellation of appointment. If no notice is given, you will be billed a $25 no
48 hour notification is required for prescription refills and test results.
If your insurance company requires an authorization/referral from your primary care physician, it is your responsibility to
make sure we have it at the time of each visit.
MEDICARE PATIENTS: SIGNATURE ON FILE I request payment of authorized Medicare benefits be made either to me or
on my behalf to Dr. Leake for any service furnished me by the listed provider/supplier. I authorize any holder of medical
information about me to release to the Health Care Financing Administration and its agents any information needed to
determine these benefits or the benefits payable to related services.
I understand my signature requests that payment be made and authorizes release of medical information necessary to pay
the claim. If “other health insurance” is indicated in Item 9 of the HCFA-1500 form or elsewhere on other approved claim
forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency
shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare
carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services.
Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.
ASSIGNMENT OF INSURANCE BENEFITS Patients with insurance please read and sign below
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private
insurance, and any other health plans to Dr. Leake. This assignment will remain in effect until revoked by me in writing.
A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible
for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information
necessary to secure the payment.
I have been given the “Notice of Privacy Practices” for the office of Dr. Leake.
Patient Signature: __________________________________________________ Date: __________________________
Physician Signature: ________________________________________________ Date: __________________________
1750 Tree Blvd., Suite 10
St. Augustine, FL 32084
Deirdre Leake, MD
Cosmetic Patient Policy
Thank you for choosing North Florida Center for Facial Plastic Surgery for your cosmetic needs. Our goal is to
make your surgical experience a pleasant one. For your convenience and to avoid any future confusion, we would
like to outline our policies and procedures for you.
A consultation is scheduled from your initial telephone call. This consultation is designed for you, the Patient
Care Coordinator and Dr. Leake, to meet and discuss your surgical needs, outline the procedure and inform you
of the fees. If insurance is involved, there will be an office visit charge.
After your consultation, if you decide to go ahead with surgery, you will work with our surgical scheduling
coordinator to select a date for your surgery.
There is a $500.00 scheduling fee deposit required before the date selected can be reserved exclusively for you.
This fee is used to cover the booking and scheduling expenses involved with your surgery. This amount will be
deducted from your total surgical cost.
At least 2-3 weeks prior to surgery (and no more than 30 days prior), you will meet with the Patient Care
Coordinator. She will review your surgical procedure and post-operative instructions with you, give you your
post-operative prescriptions with instructions for their use. Post-operative appointments are scheduled at this
time. You should have completed your medical clearance with your primary care doctor with all results received
at the North Florida Center for Facial Plastic Surgery. You will also have your pre-operative photos taken during
this appointment. Any questions you may have will be answered at this consult. On this same day you will also
have a pre-operative appointment with Flagler Hospital, plan on about 3-4 hours for both appointments.
The remaining balance on your account will be due at the pre-operative consult. We accept: Visa, MasterCard,
American Express, Money Orders, Cashiers Checks and cash. Personal checks are accepted only if paid (2) weeks
prior to surgery. No post dated checks will be accepted. There is a $30.00 charge for all returned checks.
As a courtesy to North Florida Center for Facial Plastic Surgery, PA, we ask if plans change, we be given a 10 day
notice of cancellation. This allows time to schedule another in the space originally reserved for you.
If you cancel in less than 10 days prior to your surgery date, you will forfeit your $500 deposit for expenses
incurred. If you cancel (1) day before your scheduled surgery, you will forfeit the entire surgery fee.
If you have any questions, the staff will be happy to assist you. We look forward to caring for you. Refunds will
be issued by check only, and may take up to two weeks.
Please sign and date
Signature: _____________________________________ Date: ____________________
Please carefully read and initial each section.
____YOUR INSURANCE CARD AND A VALID PHOTO ID MUST BE PRESENTED AT THE TIME OF
YOUR INITIAL VISIT OR YOUR APPOINTMENT MUST BE RESCHEDULED.
____IF YOUR INSURANCE REQUIRES AN AUTHORIZATION/REFERRAL FROM YOUR PRIMARY
CARE PHYSICIAN TO BE SEEN BY OUR DOCTORS, THEN IT IS YOUR RESPONSIBILITY TO MAKE
SURE WE HAVE RECEIVED THE REFERRAL PRIOR TO YOUR INITIAL VISIT OR YOUR
APPOINTMENT MUST BE RESCHEDULED.
Any balance incurred as a result of not having a required referral or correct insurance
information will be your responsibility. We will not bill an insurance company if we do not
have a copy of your current card and a valid photo ID at the time of visit.
If we are billing your insurance then the co-pay/co-insurance is due at time of your visit. Selfpay
patients are required to pay for their visit in full at the time of the visit.
We bill primary and secondary insurances only, as a courtesy. If we are unable to verify your
benefits, then you will be responsible for following up with your insurance.
____24-hour advanced notice is required for cancellation of an appointment. If no notice
is given, then you will be billed a $25 no-show fee. If your visit is scheduled beyond an
hour, then you will be charged an additional $25 per hour.
____48-hour notification is required for prescription refills and test results. This policy
excludes holidays and weekends.
____I have received the “Notice of Privacy Practices” for this office.
____TO OBTAIN A COPY OF MY MEDICAL RECORDS, I UNDERSTAND THAT I MUST FILL OUT A
MEDICAL RECORDS RELEASE FORM IN PERSON WITH PHOTO ID VERIFICATION. THIS POLICY IS
Please complete the following to give your authorization for our office to speak with anyone
other than yourself regarding your medical care. If left blank I understand that no one other
than me (the patient) will have the authority to speak with our offices regarding my medical
Print Name Relationship
Print Name Relationship
By signing below, I acknowledge that I have read and agreed to all of the above information:
__________________________ _______________________ _________
Patients Name (print) Patients Signature Date
NOTICE OF PRIVACY PRACTICES
Dr. Deirdre Leake
To our patients. This notice describes how health information about you (as a patient of this
practice) may be used and disclosed, and how you can get access to your health information.
This is required by the Privacy Regulations created as a result of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
Our commitment to your privacy
Our practice is dedicated to maintaining the privacy of your health information. We
are required by law to maintain the confidentiality of your health information.
We realize that these laws are complicated, but we must provide you with the
following important information:
Use and disclosure of your health information in certain special circumstances
The following circumstances may require us to use or disclose your health information:
1. To public health authorities and health oversight agencies that are authorized by
law to collect information.
2. Lawsuits and similar proceedings in response to a court or administrative order.
3. If required to do so by a law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health and safety or
the health and safety of another individual or the public. We will only make
disclosures to a person or organization able to help prevent the threat.
5. If you are a member of U.S. of foreign military forces (including veterans) and if
required by the appropriate authorities.
6. To federal officials for intelligence and national security activities authorized by
7. To correctional institutions or law enforcement officials if you are an inmate or
under the custody of a law enforcement official.
8. For Workers Compensation and similar programs.
Your rights regarding your health information
1. Communications. Your can request that our practice communicate with you about
your health and related issues in a particular manner or at a certain location. For
instance, you may ask that we contact you at home, rather than work. We will
accommodate reasonable requests.
2. You can request a restriction in our use or disclosure of your health information for
treatment, payment, or health care operations. Additionally, you have the right to
request that we restrict our disclosure of you health information to only certain
individuals involved in your care or the payment for your care, such as family
members and friends. We are not required to agree to your request; however, if
we do agree, we are bound by our agreement except when otherwise required by
law, in emergencies, or when the information is necessary to treat you.
3. You have the right to inspect and obtain a copy of the health information that may
be used to make decisions about you, including patient medical records and billing
records, but not including psychotherapy notes. You must submit your request in
writing to the office of Dr. Towne, 1750 Tree Blvd., Suite 1, St. Augustine, FL
4. You may ask us to amend your health information if you believe it is incorrect or
incomplete, and as long as the information is kept by or for our practice. To
request an amendment, your request must be made in writing and submitted to the
office of Dr. Towne as stated above. You must provide us with a reason that
supports your request for amendment.
5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of
Privacy Practices. You may ask us to give you a copy of this Notice at any time. To
obtain a copy of this notice, contact our front desk receptionist.
6. Right to file complaint. If you believe your privacy rights have been violated, you
may file a complaint with our practice or with the Secretary of the Department of
Health and Human Services. To file a complaint with our practice, contact the
office of Dr. Towne, HIPAA Officer, 1750 Tree Blvd., Suite 1, St. Augustine, FL
32084, or 904-810-5434. All complaints must be submitted in writing. You will not
be penalized for filing a complaint.
7. Right to provide an authorization for other uses and disclosures. Our practice will
obtain your written authorization for uses and disclosures that are not identified by
this notice or permitted by applicable law.
If you have any questions regarding this notice or our health information privacy policies,
please contact the office of Dr. Towne.