melanie ho erb, m.d.€¦ · consider bringing old photos of yourself or taking cell-phone pictures...

Melanie Ho Erb, M.D. A Surgeon’s Hands, A Woman’s Touch

Laser Cosmetic and Oculo-Facial Plastic Surgery

16300 Sand Canyon Ave, Suite 1007, Irvine, CA 92618 Office phone: 949-727-0102

www.MelanieHoErbMD.com www.LaserCosmeticSurgery.com

WELCOME!!

To help guide you through this process, we have list of what to expect before and during your appointment. It's long, but we hope that makes you feel more comfortable. Before your visit: 1. Print out the attached directions and map to our office, even if you have GPS and are great with directions, because

many have noted that the GPS can be wrong for our location.

2. Please note that from our building’s lobby, you will need to take 2 elevators to get to our office on the 10th

floor.

3. If you want injections of botox or fillers on your first consultation visit, then consider discontinuing aspirin and ibuprofen for 1 - 2 weeks before your injection visit.

4. Consider bringing old photos of yourself or taking cell-phone pictures of old photos, if you think that it will help in our discussions.

5. I welcome all questions, so please feel free to write down any questions and bring them with you.

6. Fill out the attached paperwork prior to your visit. I do realize that it is a lot of information to fill out. I want to make sure that I fully understand your health history before doing any treatments.

During your appointment: 1. You tell me your concerns and where you are in your life. 2. We will review and discuss your medical history. 3. I will perform a careful and thorough examination. 4. For your areas of concern, I will explain to you what the possible options are. 5. Then together, you and I will select the option that will work out best for you, your goals, and your anatomy. 6. We will look at before and after photos so that you can see possible results. 7. Based on the option that we picked, I will explain to you what to expect at every step before, during, and after the

procedure. We can talk about downtime and any restrictions. All of this is also explained in detail in another packet called “Your surgery with Dr. Erb.”

8. If you want me to, I can point out other areas that could be rejuvenated. 9. I will answer all of your remaining questions, so this is when you bring out your list. 10. We can review and summarize the procedures if you want. 11. Gina will go over pricing for the procedures. 12. You are always welcome to call, email, or visit me again if you have additional questions. I want to make sure that all of

your questions are answered and that you are comfortable. During any procedure: Immediately prior to any procedure, I will always re-discuss with you our plans to make sure that we are on the same page and ask if you have any questions. My goal is that you feel comfortable and pain-free during your procedure.


Demographics NEW PATIENT

Today's date Name: Last First Preferred First Name

Address: Street City State Zip Code

Email addresses: 1. Email address used most often 2. Do you have a Gmail address? YES NO 3. Gmail address, if you have one 4. How often do you use Gmail? DAILY MONTHLY YEARLY NEVER

Phone numbers (we will generally use your cell phone): Home Cell Work

Birth Date Age Sex

How did you hear about us? Referred by doctor: Doctor's Name Doctor's Address Doctor's Phone number Would you like us to send a letter that you were seen by us to your referring doctor? YES NO Referred by friend/family: Friend's Name Friend's address or email address Would you like us to send a thank-you note or email to your friend/family? YES NO Internet: Search words Websites viewed

Note: Does your cell phone receive text messages? YES NO


Emergency Contact Today's date: ______________________________________ Name:____________________________________________ Name of Emergency Contact: Relationship to patient: Phone (may list multiple): cell work home Email: Address: In the event of an emergency, I understand that Melanie Ho Erb, M.D. and staff may disclose information to my emergency contact listed above that may be protected by the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). I authorize Melanie Ho Erb, M.D. and staff to release protected health information to my emergency contact listed above, if deemed necessary for the emergency. This authorization is in effect until I choose a different name of emergency contact. Print Name____________________________________________ Signature_____________________________________________ Date_________________________________________________ Witness_______________________________________________


Wish List - Reason for Visit Today's date: ______________________________________ Name:____________________________________________ What issues and wishes do you want to discuss with Dr. Erb today? ___________________________________________________________________________________ ___________________________________________________________________________________ When you like to accomplish your wish? ( ) ASAP ( ) 1 mo. ( ) 3 mo. ( ) 6 mo. ( ) 1 year Would you be interest in learning more about any of the following procedures? ( ) Improvement in any skin conditions such as

o wrinkles o loose skin o brown spots o scarring

( ) Fillers (Juvederm, Restylane,etc) to improve deep lines and to add youthful volume o to hands o to lower eyelids o to temples o to lips o to other parts of face

( ) Botox to improve or prevent wrinkles ( ) Kybella to improve a double chin ( ) Laser skin resurfacing to improve skin radiance, luminosity, spots, sun damage, and fine

wrinkles ( ) Laser upper blepharoplasty upper eyelid lift for a more refreshed appearance ( ) Laser lower blepharoplasty improvement of lower eyelid bags for a more refreshed appearance ( ) Brow lift to raise brows to a more youthful position ( ) Ptosis repair to raise droopy eyelids ( ) Removal of bumps to provide a smooth appearance ( ) Gel peel treatment facials customizable peels to tighten, brighten, and hydrate ( ) Skin care multifunctional products from organic to medical grade – to deliver optimal results Patient signature____________________________ Reviewed by Erb_____________________


Medical History Today's date: ______________________________________ Name:____________________________________________ Current Medications: Prescription medication: What for? __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ Eyedrops / Nasal Sprays: What for? __________________________________ _____________________ __________________________________ _____________________ Over the counter meds / Herbal meds / Supplements: __________________________________ __________________________________ __________________________________ Allergies to medications: What happened? __________________________________ _____________________ Previous cosmetic surgery / Botox / Filler / Laser: When? By Whom? __________________________________ ______ ________ __________________________________ ______ ________ __________________________________ ______ ________ __________________________________ ______ ________ __________________________________ ______ ________ Other previous surgeries, including eye surgeries and LASIK: __________________________________ __________________________________ __________________________________ Past Trauma to the face: __________________________________ Wears contact lenses: YES___ NO___ Wears glasses: YES___ NO___ Medical History: YES NO Environmental Allergies ___ ___ High Blood Pressure ___ ___ Diabetes ___ ___ High Cholesterol or Triglycerides ___ ___ Heart Disease ___ ___ Liver Disease ___ ___ Patient signature____________________________ Reviewed by Erb_____________________


Today's date: ______________________________________ Name:____________________________________________ Medical History, continued: YES NO Kidney Disease ___ ___ Autoimmune / Rheumatological Disease ___ ___

Stroke ___ ___ Heart Attack ___ ___ Irregular Heart Beat ___ ___

Prolonged Bleeding ___ ___ Easy Bruising ___ ___ Respiratory problems ___ ___ Obstructive Sleep Apnea / Snoring ___ ___ Fainting ___ ___ Bell's Palsy ___ ___ Eye problems ___ ___ Dry Eye ___ ___ Tearing problems ___ ___ Skin problems ___ ___ Keloids ___ ___ Post Inflammatory Hyperpigmentation / darkening ___ ___ History of cold sores / oral herpes simplex ___ ___ Accutane use ___ ___ Hydroquinone use ___ ___ Valvular heart disease ___ ___ Bacterial endocarditis ___ ___ Collagen vasular disease (lupus, scleroderma) ___ ___ Immunological disorder (vitaligo, thyroiditis) ___ ___ HIV / AIDS ___ ___ Hepatitis A, B, and/or C ___ ___ Psychological problems ___ ___ Social History: Occupation ____________ Alcohol Use YES___ NO___ Type of alcohol____________ How often_____________ Tobacco Use YES___ NO___ How many per day_________ How many years________ Drug use YES___ NO___ Skin Typing assessment quiz results (see quiz attached)______________________________________ Ethnicity / Ancestry / Heritage__________________________________________________________ Patient signature____________________________ Reviewed by Erb_____________________


Today's date: ______________________________________ Name:____________________________________________ Review of Systems: Any other active problems, not previously mentioned or listed above, related to: YES NO IF YES, PLEASE EXPLAIN Constitutional (e.g., fever, weight loss) ___ ___ Eyes ___ ___ Ears, Nose, Mouth, Throat ___ ___ Cardiovascular ___ ___ Respiratory ___ ___ Gastrointestinal ___ ___ Genitourinary ___ ___ Musculoskeletal ___ ___ Integumentary (skin and/or breast) ___ ___ Neurological ___ ___ Psychiatric ___ ___ Endocrine ___ ___ Hematologic/Lymphatic ___ ___ Allergic/Immunologic ___ ___ Family history: (mother, father, grandparents, siblings only) YES NO IF YES, WHO Heart disease ___ ___ High blood pressure ___ ___ Diabetes ___ ___ Autoimmune / Rheumatologic disease ___ ___ Patient signature____________________________ Reviewed by Erb_____________________ updated 01/23/2017

HIPAA Notice of Privacy Practices Melanie Ho Erb, M.D., Inc.

16300 Sand Canyon Avenue, Suite 1007

Irvine, CA 92618

949-727-0102

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out

treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also

describes your rights to access and control your protected health information. “Protected health information” is information

about you, including demographic information, that may identify you and that relates to your past, present or future physical

or mental health or condition and related health care services.

Your Rights Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not

inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a

civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits

access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use

or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.

You may also request that any part of your protected health information not be disclosed to family members or friends who

may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must

state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to

permit use and disclosure of your protected health information, your protected health information will not be restricted. You

then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an

alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have

agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for

amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement

and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health

information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right

to object or withdraw as provided in this notice.

Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with

respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in

person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Print Name:__________________________ Signature______________________ Date______________


Melanie Ho Erb, M.D., Inc

16300 Sand Canyon Ave., Suite 1007, Irvine, CA 92618

Phone 949.727.0102 Fax 949.753.0291

PATIENT PHOTOGRAPHIC AUTHORIZATION & RELEASE

I, _______________________________________________________________ Name of Patient

hereby authorize Melanie Erb, M.D. and/or staff to photograph me while under the care of

Melanie Erb, M.D. I agree that the photographs may be used for my medical chart, patient

education, scientific publications, and promotional materials.

_________________________________________________________________________

_________________________________________________________________________

I agree to hold harmless Melanie Erb M.D., her agents and employees, from any liability

resulting from or arising in connection with the taking, publication and release of these photographs.

I understand that I have the right to revoke this authorization in writing at anytime.

I understand that I may refuse to sign this authorization and such refusal will have no effect

on the medical treatment I receive from Melanie Erb, M.D.

_________________________________ Signature of patient

_________________________________ Signature of Witness

_________________________________ Date

melanie ho erb, m.d.€¦ · consider bringing old photos of yourself or taking cell-phone pictures...

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