bradley k. becker, d.o., p.l.l

Bradley K. Becker, D.O., P.L.L.C

18555 N. 79th Ave., Suite B-102, Glendale, AZ 85308 - Ph: 602-610-9111 Fax: 623-471-5180

DATE: ___________________ NAME: ______________________________________ DOB: _______________ AGE: _____ SEX: MALE FEMALE HEIGHT: _________________ WEIGHT: ______________________ How did you hear about us? Magazine add, lnstagram etc.: _____________________________ History: CC ____________________________________________________________________ _____________________________________________________________________________ BREAST: MOHS: Last Mammogram: _________ How long lesion present: ________ U/S of Breast: __________ Original Biopsy Date: __________ Breast Biopsy: _________ Prior Biopsy: ____________ Breast Surgery: ________ Pathology: _____________ History of Breast Feeding: ______ sec ___ sec ___ Melanoma ____ Number of Pregnancies: _____ Previous History of Skin Cancer: ______ Current Bra Size: ________ PAST MEDICAL HISTORY: Age of Menses: ________ ______________________________ C - Sections: __________ ______________________________ ______________________________ Right Left ______________________________ ______________________________

FAMILY HISTORY: PAST SURGICAL HISTORY: Diabetes ______________________________ Skin Cancer ______________________________ Hypertension ______________________________ Cancer ______________________________ Heart Disease ______________________________ ALLERGIES: ______________________________ ______________________________ CURRENT MEDICATIONS: ________________________________________________________ SOCIAL HISTORY: Cig (#day/#yrs) ___________ Alcohol (oz/day) ___________ Coffee / Tea (cups/day) ________ SUMMARY: _____________________________________________________________________________________________________________________________________



Notice of Privacy Practices: Use of Disclosure of Health Information Protected under HIPAA

This document provides a summary of how medical information about you may be used and disclosed and how you can obtain access to this information. We understand that medical information about you and your health is personal. We are committed to protecting your medical information. It is our policy that the privacy of your protected health information (PHI) be uncompromised while still allowing necessary access to assure that the medical care you receive is appropriated and of the highest possible quality. We pledge to you that we will protect the confidentiality of information provided to us. Your information will be used in the following manner, known as Treatment, Payment, and Healthcare Operations (TPO): 1. To provided medical treatment and/or services. 2. To bill third party payers, when appropriated, for treatment you receive from us. 3. To facilitate the mechanisms which allow the operation of our facility. In every use of your information, we will be responsible custodians of your PHI and adhere to the standards set forth in the legislation which created these privacy practices. We recognize that all patients have the right to privacy in matters relating to their health and we will not use your PHI for uses outside of our facility without your express permission. You have the following rights regarding to the medical information we maintain about you: 1. To inspect and copy information that may be used to make decisions about your care. 2.To request restrictions or limitations on the medical information we use or disclose about you for treatment, payment, or health care operations. While we are not required to agree to your request, we will do our utmost to comply unless the information is needed to provide emergency treatment. 3. To amend the PHI we maintain if you believe that the medical information, we have about you is incorrect or incomplete. 4. To request an accounting of disclosures we have made for uses other than our own. 5. To request confidential communications; i.e., that we communicate with you in a certain manner or at a certain location. 6. To receive a paper copy of this notice. All members of our staff are committed to adhering to the conditions set forth in this notice of privacy practices. Any violations will be grounds for disciplinary action. We reserve the right to change this policy in the future; such changes will be available to all patients. Should you believe that your privacy rights have been violated, you may file a complaint with this facility or with the State oversight department; all complaints must be submitted in writing. You will not be penalized for filing a complaint.

Patient acknowledgement:

I acknowledge receipt of this information regarding my right to PHI privacy. I have received information regarding the providers of care in this organization, a copy of the Patient's Bill of Rights and Responsibilities, information regarding the grievance process and information regarding the infection control the process of this organization, and I understand all the information received.

Signature: _____________________________________ Date: __________________________

Bradley K. Becker, D.O., P.L.L.C18555 N. 79th Ave., Suite B-102, Glendale, AZ 85308 - Ph: 602-610-9111 Fax: 623-471-5180

PATIENT INFORMATION NAME: ______________________________________ DOB: _______________ Age: _____ Street Address: ________________________________________________________________ City: _____________________________________ State: ______________ Zip: ____________ SS#: ______________________________ Sex: Male Female Phone Home: ______________________ Cel: _________________ Work: _________________ Email Address: ________________________________________________________________ Preferred Pharmacy Address: _____________________________________________________ _____________________________________________________________________________

GUARANTOR INFORMATION NAME: ______________________________________ DOB: _______________ Age: _____

Street Address: ________________________________________________________________ City: _____________________________________ State: ______________ Zip: ____________ SS#: ______________________________ Sex: Male Female Phone Home: ______________________ Cel: _________________ Work: _________________ Email Address: ________________________________________________________________ _____________________________________________________________________________

INSURANCE INFORMATION Primary Ins: _________________________________________ Start Date: ________________ Claim Address: ________________________________________________________________ Policy #: _____________________________________ Group #: ________________________ Policy Holder: ________________________________ Relation to Patient: ________________ Employer: ___________________________________ DOB: ____________________________

Secondary Ins: ______________________________________ Start Date: _________________ Claim Address: ________________________________________________________________ Policy #: _____________________________________ Group #: ________________________ Policy Holder: ________________________________ Relation to Patient: ________________ Employer: ___________________________________ DOB: ____________________________

Primary Physician: __________________________________ Phone: _____________________ Secondary Physician: ________________________________ Phone: _____________________ Emergency Contact: ________________________________ Phone: _____________________

By signing this form, I certify that the information provided is accurate and true to the best of my knowledge. I hereby authorize Dr. Bradley Becker, D.O. to furnish the above insurance company(ies) all medical information necessary to process any appropriate claims. I authorize payment of medical benefits to Bradley Becker, D.O. I understand that I am responsible for paying for services rendered, including attorney's fees and cost of collection in the event of default.

SIGNATURE: ________________________________ Date: ________________________________



DATE: ___________________ NAME: ______________________________________ DOB: _______________ AGE: _____ SEX: MALE FEMALE HEIGHT: _________________ WEIGHT: ______________________ How did you hear about us? Magazine add, lnstagram etc.: _____________________________ History: CC ____________________________________________________________________ _____________________________________________________________________________ BREAST: MOHS: Last Mammogram: _________ How long lesion present: ________ U/S of Breast: __________ Original Biopsy Date: __________ Breast Biopsy: _________ Prior Biopsy: ____________ Breast Surgery: ________ Pathology: _____________ History of Breast Feeding: ______ sec ___ sec ___ Melanoma ____ Number of Pregnancies: _____ Previous History of Skin Cancer: ______ Current Bra Size: ________ PAST MEDICAL HISTORY: Age of Menses: ________ ______________________________ C - Sections: __________ ______________________________ ______________________________ Right Left ______________________________ ______________________________

FAMILY HISTORY: PAST SURGICAL HISTORY: Diabetes ______________________________ Skin Cancer ______________________________ Hypertension ______________________________ Cancer ______________________________ Heart Disease ______________________________ ALLERGIES: ______________________________ ______________________________ CURRENT MEDICATIONS: ________________________________________________________ SOCIAL HISTORY: Cig (#day/#yrs) ___________ Alcohol (oz/day) ___________ Coffee / Tea (cups/day) ________ SUMMARY: _____________________________________________________________________________________________________________________________________

Bradley K. Becker, D.O., P.L.L.C Cosmetic Surgery, Plastic & Reconstructive Surgery


IMPLANT REMOVAL AND DISPOSAL FORM

Date: _______________ I, ______________________________, DOB: ___________________, consent the removal Of my implants. The reason for this procedure is: _________________ and will be performed by Bradley Becker, D.0., P.L.L.C. and his designated assistant(s). I understand that after removing the implants, they are cleaned but not sterilized. __________ (Initial) I understand that no matter what kind of material the implant is made of or where it existed inside the body, all implants, once extracted, are treated as medical waste and are considered a biological hazard. They contain blood or other bodily fluids and matter; they must never be disposed of with municipal trash. __________ (Initial) I understand, I am solely responsible for the disposal of the implants in safe way. __________ (Initial) I understand that Dr. Bradley Becker and/or Surgical Center are no longer liable for these implants after removal. ________ (Initial) ______________________________ _________________ Signature of Patient Date

Bradley K. Becker, D.O., P.L.L.C Cosmetic Surgery, Plastic & Reconstructive Surgery

18555 N. 79th Ave., Suite B-102, Glendale, AZ 85308 - Ph: 602-610-9111 Fax: 623-471-5180 PHOTOGRAPHY CONSENT I consent to the taking of photographs or video by Dr. Bradley K. Becker, associates or representatives of myself or parts of my body in connection with the procedure/surgery intended to be performed. I understand that photographs may be taken before, during and/or after my procedure or surgery as a routine part of my medical care and that all photographs or video will be kept strictly confidential. Signature: _________________________________ Date: ____________________ _____________________________________________________________________________

RELEASE OF PHOTOGRAPHS CONSENT

I authorize the use of my photographs or video in the formats listed below. I waive any right to inspect or approve the finish product, advertising or other copy that may be u5ed in connection with the option below. understand that I will never be identified by name in any use of these photographs or video, but that in some circumstances they may portray features which me make my identity recognizable. Please initial or check YES or No for each item below: ___YES ___ NO For our office photo album for prospective patients. ___YES ___ NO For our website for prospective patients. ___YES ___ NO For print advertisements or television ___YES ___ NO For our Social media (i.e., Facebook, Instagram, etc.) for prospective patients or for education purposes I release and discharge Dr. Bradley K. Becker, associates and representatives from all rights and may have in the photographs or video and from any claim I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of photographs or video. This consent may be revoked at any with written consent. I certify that I have read the above Authorization and Release and fully understand its terms. Signature: _______________________________________ Date: ______________________ Print Name: _________________________________________________________________

SURGERY DEPOSIT

We want to help our patients fully understand their financial obligations when scheduling surgery at our practice, along wiU1 our payment and cancellation policies prior to undergoing surgery with Dr. Becker. When you schedule your surgery, we must secure a time in the operating room at the surgery center as well as the anesthesia. Both the facility and Anesthesia group hold Dr. Becker accountable if this time is not used. Furthermore, we must turn down every other patient who wants surgery on the day and the time we have reserved on your behalf. The Surgical Deposit Agreement is outlined below. When you feel you understand the contents of this form, and agree to the terms, please sign and date on the line indicated below. I understand that once my surgery is scheduled with Dr. Becker and the operating room is reserved at a specific time for me, and is no longer available to other patients. Therefore, I agree to submit a $1,000 surgical deposit at the time I request my surgery to be scheduled. All surgical fees must be paid one week prior to the date of your surgery. The operating room and anesthesia fees are all included in your total cost to Dr. Becker.

Cancellation and Rescheduling Policy: Cancellation at least 4 weeks prior to surgery date -Full Refund of Deposit. Cancellation Jess than 2 weeks prior to surgery date -Forfeiture of $1,000 Deposit. Cancellation 3 days or less prior to surge1y -Forfeiture of 50% of Surge1y cost. There will be no funds held back in the event of rescheduling or cancellation by us, or in the event of a documentable medical reason with a treating doctor's statement. I UNDERSTAND AND AGREE TO THE ABOVE TERMS Please sign and return. Thank you. Signature: ______________________ Date:________________

bradley k. becker, d.o., p.l.l

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