NEW PATIENT FORM Arviv Medical Aesthetics 11327 Countryway Boulevard
Tampa, FL 33626 (813) 855-0111
Full Name: Today’s Date:
Date of Birth: Phone:
Address: City/State/Zip:
Email: Gender (Male/Female)
Emergency Contact/Relation: How did you hear about us:
Please check the procedure you will be receiving:
□ Laser Hair Removal □ Laser Vein Reduction □ CO2 Skin Resurfacing
□ Erbium/Yag Laser Resurfacing □ IPL (Intense Pulsed Light) □ Laser Tattoo Removal □ Laser Permanent Makeup Removal □ Wart/Mole Removal □ Skin Tag Removal □ Pigmented Lesions □ Toenail Fungus Treatment □ Triniti Laser/Photofacial
□ Ultrasonic Cavitation □ Infrared Hair Growth □ Electrolysis
□ PRP Treatment □ Microneedling □ Radio Frequency
□ Botox/Fillers □ Chemical/Glycolic Peel □ Vi Peel
□ Earlobe Reconstruction □ IV Therapy □ Keloids
□ Liposuction □ Hormone Replacement Therapy □ Wellness Exam / Annual Exam
□ Weight Loss □ Endermology Cellulite Treatment Other:_________________________ State any and all treatments you have had before this procedure, where it was performed, and when it was performed:
Please Circle:
Pregnant/Breastfeeding YES/NO Smoking YES/NO
Diabetes YES/NO Arthritis YES/NO
Herpes/Cold Sores YES/NO Any Blood Disease YES/NO
Histamine (Hives) YES/NO Skin Cancer YES/NO
Epilepsy/Lupus YES/NO Allergies YES/NO
Keloids/Scarring YES/NO Present Illness YES/NO
Cardiac Problems YES/NO Skin Disorder or Lesion YES/NO
Bleeding Disorders YES/NO Hormonal Imbalance YES/NO
Bruises Easily YES/NO Thyroid YES/NO
HIV/AIDS YES/NO High Blood Pressure YES/NO
Hepatitis YES/NO Other YES/NO
Surgical History (Procedure/Date):
Have you been using for the last 2 weeks any Alpha Hydroxy Acid products (those containing glycolic or lactic acid), salicylic acid products, retinoids (Retin A, Renova, Differin and Tazorac) and other topical acne medications such as Benzoyl Peroxide. YES / NO Not Applicable
Have you been using Accutane (acne medication)? YES / NO Not Applicable If so, when was the last time you used it?
List all Present Medications:
(Accutane, Aspirin, Antibiotics, Cortisone, Any Photosensitive medications such as Hormones, Oral Contraceptives, any Depression Medications or Mood-Altering Drugs, St. John’s Wart)
Skin: Light / Medium / Tan / Olive / Brown / Dark Brown Tanning / Sun Exposure: Daily / Weekly / Monthly / Yearly
Race/ Ethnicity: Caucasian / Hispanic / Mediterranean / Asian / Indian / Black / African American / Other: Skin Type: 1 / 2 / 3 / 4 / 5 / 6
List Current Skin Care Regimen and Products:
Insurance Information (please provide a copy of card)
Insurance Name: Insurance Phone #:
Insurance Address: Policy #:
Policy Holder’s Name: Policy Holder’s DOB:
Relationship to Patient: Copay Amount:
REFUND POLICY: Any services purchased, must be paid in advance. If a service or package of services is purchased, and the services were NOT rendered, you may cancel and request a refund in writing. Refunds will be provided, however, a $100 Consultation Fee will be deducted from the total amount originally paid. If services were rendered for a package, and a refund is requested prior to completion of a package, the cost of a FULL PRICED treatment (NOT package discount price) will be deducted from the total amount paid for services rendered, in addition to the $100 consultation fee, and then the difference will be refunded. Once ALL services/packages have been rendered NO REFUND POLICY will be applied. If you elect to get a refund, you waive any and all right to arbitrate or sue the practice, the physician or any staff affiliate. 24 HOURS CANCELLATION POLICY: Confirmation of your appointments is a courtesy call not an obligation. It is the client’s full responsibility to keep track of his/her scheduled appointments. If the client fails to notify us of the appointment cancellation at least 24 hours in advance, the no-show will be counted as used treatment of the client’s package deal or a $40 charge to accommodate the licensed physician/technician’s time.
It is my understanding that this office is relying on this information I have provided. I affirm that all information above is true and correct.
ARBITRATION AGREEMENT
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by Florida law, and not by a lawsuit or resort to court process except as Florida law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must Be Arbitrate: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of Florida law applicable to health care providers, shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure §667.7, Civil Code §3333.1 and §3333.2.
Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Florida statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitration shall be governed by the Florida Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature and if not revoked will govern all medical services received by the patient.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial below:
Effective as of the date of first medical services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
NOTICE: By signing this contract, you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial.
ARVIV MEDICAL AESTHETICS PATIENT SIGNATURE
11327 Countryway Blvd. Tampa, Florida 33626
Tali Arviv, MD PRINT NAME
PRIVACY POLICY
This practice is committed to maintaining the privacy of your health information, which includes information about your health condition and the care and treatment you receive from this practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This notice details how your health
information may be used and disclosed to third parties. This notice also details your rights regarding your health information.
State and federal laws require this practice to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this notice. This practice is required by state law to maintain a higher level of confidentiality with respect to HIV testing and sexually-transmitted diseases and is provided for under federal law. It is the right of this practice to change our privacy practices provided the law permits the changes. Before we make a significant change, this notice will be amended to reflect the changes and we will distribute any revised privacy notice to you prior to implementation upon request. We reserve the right to make any changes in our privacy practices and the new terms of our notice effective for all health information maintained, created and/or received by us before the date changes were made. You may request a copy of our privacy notice at any time by contacting our office. We will keep your health information confidential. We may use and/or disclose health information without written consent from you in the
following instances:
TREATMENT: In order to provide you the health care you require, the practice may use your health information to provide you with our professional services. We have established “minimum necessary or need to know” standards that limit various staff members access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.
DISCLOSURE: In order to provide you the health care you require, the practice will provide your health information to those health care professionals, whether on the practices staff or not, directly involved in your care so that they may understand your health conditions and needs. These professionals will have a privacy and confidentiality policy like this one. The health information about you may be disclosed to your family, friends and/or other persons that you choose to be involved in your care, only if you agree that we may do so.
PAYMENT: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may be involved in mailing statements and/or collecting unpaid balances.
EMERGENCIES: We may use or disclose health information for the purpose of obtaining or rendering emergency treatment to you or to assist in the notification of a family member or anyone responsible for your care in the case of an emergency involving your care. If at all possible, we will provide you with an opportunity to object to this use or disclosure. We will use our professional judgment to disclose only that information directly relevant to your care. HEALTHCARE OPERATION: In order for the practice to operate in accordance with applicable law and insurance requirements, it may be necessary to compile, use, and/or disclose your health information. For example, the practice may use your health information in order to evaluate the performance of the practice’s personnel in providing care to you for ongoing measurement of quality assurance.
REQUIRED BY LAW: We may use or disclose health information when we are required to do so by law. This would include the court orders, subpoenas, discovery requests or other lawful processes. We will use and disclose information when requested by national security, intelligence and other state and federal officials and/or if you are an inmate under custody of law enforcement. The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances.
ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or other crime. This information will be disclosed only to the extent necessary to prevent serious threat to your health or safety or that of others.
PUBLIC HEALTH RESPONSIBILITIES: We will disclose health care information to report problems with products, reactions to medications, disease/infection exposure and to prevent and control disease, injury and/or disability.
MARKETING: We will not use your health information for marketing purposes without your written authorization. COMMUNICATION BARRIERS: We may use or disclose health information without consent if, due to significant communication barrier or inability to communicate, we have been unable to obtain your consent and we determine, with professional judgment, that your consent to receive treatment is clearly inferred from the circumstances.
APPOINTMENT REMINDER: This practice may contact you to provide appointment reminders or information about health-related services. The following appointment reminders may be used by this practice. A postcard mailed to you at the address provided by you, telephoning your home or work location and notification by email using an email address furnished by you.
SIGN-IN LOG: This practice maintains a sign in log for individuals seeking care and treatment in the office. This log is in a position where staff can readily see who is seeking care in the office. This information may be seen by, and is accessible to, others who are seeking care or services in the practice’s office.
Your privacy rights as our patient:
ACCESS: You have the right to inspect and obtain a copy of your health information of an individual for whom you are a legal guardian, as provided by law. To do so, you will need to make your request in writing to the Practices Privacy Officer. If you want the copies to be mailed to you, postage may be charged.
AMENDMENT: You have the right to amend your health information as required by law. To request an amendment, you must submit a written request to the Practices Privacy Officer. You must provide a reason that supports your request. The practice may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the practice, if the information is not part of your health information maintained by this practice, or if the information to be amended is already complete and accurate. If you disagree with the practice’s denial, you have the right to submit a written statement of disagreement.
NONROUTINE DISCLOSURES: You have the right to receive a list of non-routine disclosures we have made of your health care information. When we make your routine disclosure of your information to professionals for treatment and/or payment purposes, we do not keep a record of disclosures. You can request the practice will comply unless the
information is needed in order to provide you with emergency treatment.
RESTRICTIONS: You have the right to request that we place additional restrictions on our use or disclosures of your health information. However, the practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practices Privacy Officer. In your written request, you must inform us of what information you want to limit, and to whom you want the limits to apply. If the practices agrees to your request, the practice will comply unless the information is needed in order to provide you with emergency treatment.
QUESTIONS/COMPLAINTS: You have the right to file a complaint with us if you feel your privacy rights have been violated. Your complaint must be directed in writing to our Privacy Officer. You also have the right to complain to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SE, Room 509F, HHH Building, Washington D.C. 20201 202/61 9/0257 or to the Florida Attorney General, Office of the Attorney General, PL-01 The Capital, Tallahassee, FL 32399 850/414/3300. We support your right to the privacy of your information and would not retaliate in any way if you chose to file a complaint.
PLEASE LIST THOSE YOU WANT TO HAVE ACCESS TO YOU PERTINENT MEDICAL INFORMATION
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them. I understand this notice. I understand that this notice will be placed in my patient chart and maintained for six years.
Patient Name (please print) Date
