North Florida Center For Facial Plastic Surgery, P

North Florida Center For Facial Plastic Surgery, P

Deirdre Leake, M.D.

Cheron Haggard, L.E. Amanda Alton, L.E.


Client Information

Name ______________________________________________________________________________________

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 ________________________________

Insurance ___________________________________________________________________________________

How did you hear about Dr. Leake? _______________________________________________________________

May we send you information via mail or email? _____________________________________

Medical Evaluation

What area(s) of the face are you interested in having cosmetically or functionally improved? ___________________



Medical History

Family Physician: _____________________________________________________________________________

Phone Number: _____________________________________

Address: ____________________________________________________________________________________

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? ________________________________________


Cosmetic Use

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? _____________________________


List any drug allergies (including local anesthetics, over the counter medications, tape or latex): ________________



Social History

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

________________________________ Chest

Shortness of breath

Neurological Chronic lung disease

Convulsions Frequent cough

Seizures Asthma

Memory loss Chest pain

1750 Tree Blvd., Suite 10

St. Augustine, FL 32084


Hematological Neck

Bleeding disorder: self/family Lumps in neck

Blood transfusions Thyroid problems

Blood clots Diabetes

GU Cardiovascular

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

Sinus conditions

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 ______________________________

Daytime sleepiness

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

show fee.

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.

Surgery Deposit

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.

Pre-Operative Consult

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.

Final Payment

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.







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.




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


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.

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