Mark R. Jaffe, M.D. 5744 LBJ Freeway Suite 180

Dallas, Texas 75204

PATIENT INFORMATION

Reason for today’s visit: _____________________________________________________________________

Name ______________________________________________________ Date of Birth ____/____/_________

Address __________________________________________________________________________________

Email _____________________________________________________________________________________

City, State _________________________________________________________ Zip ___________________

Home Phone (____) ________________________ Social Security Number ____________________________

Cell Phone (____) __________________________ Sex: Male ____ Female ____

Work Phone (____) _________________________ Employed By ____________________________________

Occupation ________________________________________________________________________________

Spouse’s Name ___________________________ Spouse’s Employer _________________________________

Contact in the case of Emergency __________________________ Phone (____)_________________________

Pharmacy Phone Number (____)_________________________ Pharmacy Name ________________________

INSURANCE INFORMATION

Primary Insurance Carrier ____________________________________________________________________

Secondary Insurance Carrier __________________________________________________________________

How were you referred to the Dallas Eyelid Center?

Friend or Acquaintance? Name? _______________________________________________________________

Were you referred by a physician? Name? _________________ Specialty? ____________ City? ___________

Other? Please explain: _______________________________________________________________________

Who is your Primary Care Physician? ____________________City? ______________Phone # _____________

Name: _______________________________________________ Todayʼs Date: __________________________

REVIEW OF SYSTEMS For new patients, established patients who may be having a new problem, or our patients who we havenʼt seen for a while, we need to update our records as to your general medical health. In each area, if you are not having any difficulties, please check “No Problems.” If you are experiencing any of the symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or explain any that may not be listed. If you have any questions about this, please ask one of the technicians, or your doctor. Const. (Health in General) ❑ No Problems Lack of energy, unexplained weight gain or weight loss, loss of appetite, fever, night sweats, pain in jaws when eating, scalp tenderness, prior diagnosis of cancer. Other: _______________________________________________________________ Ears, Nose, Mouth & Throat ❑ No Problems Difficulty with hearing, sinus problems, runny nose, post-nasal drip, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness. Other: _________________________________________________________________ C-V (Heart & Blood Vessels) ❑ No Problems Irregular heartbeat, racing heart, chest pains, swelling of feet or legs, pain in legs with walking. Other: _______________________________________ Resp. (Lungs & Breathing) ❑ No Problems Shortness of breath, night sweats, prolonged cough, wheezing, sputum production, prior tuberculosis, pleurisy, oxygen at home, coughing up blood, abnormal chest x-ray. Other: _______________________________________________________________ GI (Stomach & Intestines) ❑ No Problems Heartburn, constipation, intolerance to certain foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained change in bowel habits, incontinence. Other: ________________________________________________ GU (Kidney & Bladder) ❑ No Problems Painful urination, frequent urination, urgency, prostate problems, bladder problems, impotence. Other: ______________________________________ MS (Muscles, Bones, Joints) ❑ No Problems Joint pain, aching muscles, shoulder pain, swelling of joints, joint deformities, back pain. Other: ___________________________________________ Integ. (Skin, Hair & Breast) ❑ No Problems Persistent rash, itching, new skin lesion, change in existing skin lesion, hair loss or increase, breast changes. Other: ______________________________ Neurologic (Brain & Nerves) ❑ No Problems Frequent headaches, double vision, weakness, change in sensation, problems with walking or balance, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of visual loss. Other: __________________________________________ Psychiatric (Mood & Thinking) ❑ No Problems Insomnia, irritability, depression, anxiety, recurrent bad thoughts, mood swings, hallucinations, compulsions. Other: _______________________ Endocrinologic (Glands) ❑ No Problems Intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst, changes in sex drive. Other: _______________________ Hematologic (Blood/Lymph) ❑ No Problems Easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia, unexplained swollen areas. Other: _______________________________________ Allergic/Immunologic ❑ No Problems Seasonal allergies, hay fever symptoms, itching, frequent infections, exposure to HIV. Other: ___________________________________________________

Mark R. Jaffe, M.D. 5744 LBJ Freeway Suite 180

Dallas, Texas 75204

INSURANCE RELEASE

I understand that my office visits will be filed under my insurance provided and that this is not a free consultation to discuss my eyelid condition. ________Initials

I understand that I am responsible for my bill and portion not paid by my insurance and payment is due the day services are rendered. If Dr. Jaffe is forced to turn me into collections, I will be responsible for any and all fees associated with collecting my debt. If an insurance claim is to be filed, I request that payment of authorized benefits be made to me or on my behalf to the Dallas Eyelid Center for any services furnished to me. I authorize direct payment by insurance companies to my physicians, and I release any information acquired in the course of my examination or treatment to those insurance companies. I authorize any holder of medical information about me to be released to the Health Care Financing Administration (HCFA) and its agents any information needed to determine these benefits or the benefits payable for related services. I voluntarily request Mark R. Jaffe, MD as my physician, and such associates, technical assistants and other health care providers as they may deem necessary to treat my condition. I hereby authorize Dr. Mark R. Jaffe and such associates, technical assistants and other healthcare professionals to perform such procedures as they, in the exercise of their professional judgment, deem necessary.

PATIENT CONSENT FORM NOTICE OF PRIVACY PRACTICES

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your r ights under the law. You have the r ight to review our Notice before signing this consent. The terms of our Notice may change. I f we change our Notice, you may obtain a revised copy by contacting our off ice.

You have the r ight to request that we restr ict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restr ict ion, but i f we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, or health care operations. You have the right to revoke this consent, in writ ing, signed by you. However, such a revocation shall not affect any disclosures we have already made in rel iance on your prior consent. The Practice provides this form to comply with the Health Insurance Portabil i ty and Accountabil i ty Act of 1996 (HIPAA).

The patient understands that:

1) Protected health information may be disclosed or used for treatment, payment, or health care operations.

2) The Practice has a Notice of Privacy Practices and that the patient has the opportuni ty to review this Notice.

3) The Practice reserves the right to change the Notice of Privacy Policies.

4) The patient has the right to restr ict the uses of their information, but the Practice does not have to agree to those restr ict ions.

5) The patient may revoke this Consent in writ ing at any t ime and al l future disclosures wil l then cease.

6) The Practice may condit ion treatment upon the execution of this Consent.

7) The patient consents to verbal, writ ten, and electronic communications.

PRINT Patient’s Name: _________________________________________________________________ Patient’s Signature (or Legal Representative): _____________________________________________ I f Legal Representative, relat ionship to Patient: ______________________________________________ Date: ________________________________

Mark R. Jaffe, M.D. 5744 LBJ Freeway Suite 180

Dallas, Texas 75204

INSURANCE RELEASE

I understand that my office visits will be filed under my insurance provided and that this is not a free consultation to discuss my eyelid condition. ________Initials

I understand that I am responsible for my bill and portion not paid by my insurance and payment is due the day services are rendered. If Dr. Jaffe is forced to turn me into collections, I will be responsible for any and all fees associated with collecting my debt. If an insurance claim is to be filed, I request that payment of authorized benefits be made to me or on my behalf to the Dallas Eyelid Center for any services furnished to me. I authorize direct payment by insurance companies to my physicians, and I release any information acquired in the course of my examination or treatment to those insurance companies. I authorize any holder of medical information about me to be released to the Health Care Financing Administration (HCFA) and its agents any information needed to determine these benefits or the benefits payable for related services. I voluntarily request Mark R. Jaffe, MD as my physician, and such associates, technical assistants and other health care providers as they may deem necessary to treat my condition. I hereby authorize Dr. Mark R. Jaffe and such associates, technical assistants and other healthcare professionals to perform such procedures as they, in the exercise of their professional judgment, deem necessary.

PATIENT CONSENT FORMPATIENT CONSENT FORM NOTICE OF PRIVACY PRACTICESNOTICE OF PRIVACY PRACTICES

Our Notice of Privacy Practices provides information about how weOur Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your r ights under the law. You have the r ight to review our Notice beforNotice contains a Patient Rights section describing your r ights under the law. You have the r ight to review our Notice before signing this e signing this consent. The terms of our Notice may change. I fconsent. The terms of our Notice may change. I f we change our Notice, you may obtain a revised copy by contacting our off ice.we change our Notice, you may obtain a revised copy by contacting our off ice.

You have the r ight to request that we restr ict how protected health information about you is used or disclosed for treatment,You have the r ight to request that we restr ict how protected health information about you is used or disclosed for treatment, payment, or payment, or health care operations. We are not rehealth care operations. We are not required to agree to this restr ict ion, but i f we do, we shall honor that agreement.quired to agree to this restr ict ion, but i f we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment,By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, or health or health care operations. You have the right care operations. You have the right to revoke this consent, in writ ing, signed by you. However, such a revocation shall not affect any to revoke this consent, in writ ing, signed by you. However, such a revocation shall not affect any disclosures we have already made in rel iance on your prior consent. The Practice provides this form to comply with the Healtdisclosures we have already made in rel iance on your prior consent. The Practice provides this form to comply with the Healt h Insurance h Insurance Portabil i ty and AccPortabil i ty and Accountabil i ty Act of 1996 (HIPAA).ountabil i ty Act of 1996 (HIPAA).

The patient understands that:The patient understands that:

1)1) Protected health information may be disclosed or used for treatment, payment, or health care operations.Protected health information may be disclosed or used for treatment, payment, or health care operations.

2)2) The Practice has a Notice of Privacy Practices and that the patient has the opportuniThe Practice has a Notice of Privacy Practices and that the patient has the opportuni ty to review this Notice.ty to review this Notice.

3)3) The Practice reserves the right to change the Notice of Privacy Policies.The Practice reserves the right to change the Notice of Privacy Policies.

4)4) The patient has the right to restr ict the uses of their information, but the Practice does not have to agree to those The patient has the right to restr ict the uses of their information, but the Practice does not have to agree to those restr ict ions.restr ict ions.

5)5) The patient may revokThe patient may revoke this Consent in writ ing at any t ime and al l future disclosures wil l then cease.e this Consent in writ ing at any t ime and al l future disclosures wil l then cease.

6)6) The Practice may condit ion treatment upon the execution of this Consent.The Practice may condit ion treatment upon the execution of this Consent.

7)7) The pThe patient consents to verbal, writ ten, and electronic communications.atient consents to verbal, writ ten, and electronic communications.

PRINT Patient’s Name: PRINT Patient’s Name: __________________________________________________________________________________________________________________________________ Patient’s SiPatient’s Signature (or Legal Representative):gnature (or Legal Representative): __________________________________________________________________________________________ I f Legal Representative, relat ionship to Patient: ______________________________________________I f Legal Representative, relat ionship to Patient: ______________________________________________ Date: _______Date: _________________________________________________________

Mark R. Jaffe, M.D. 5744 LBJ Freeway Suite 180

Dallas, Texas 75204

Patient Portal Consent Form

Access to this secure Patient Portal is an optional service, and I may suspend or terminate it at any time and for any reason. I understand that my access to this Portal will not affect the current level of care I’m already receiving from Jaffe Cosmetic Eyelid Center. I acknowledge that I have read and fully understand this consent form. I have been given risks and benefits of the patient portal and agree that I understand the risks associated with online communications between my physician and patient, and consent to the conditions outlined herein. I acknowledge that using the patient portal is entirely voluntary and will not impact the quality of care I receive from Jaffe Cosmetic Eyelid Center should I decide against using the patient portal. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidlines that my physician may impose for online communications. I understand that this agreement will remain in effect for 12 months. At the end of that time, I will be asked to renew my confidential email and Patient Portal Login. It is my responsibility to notify Jaffe cosmetic Eyelid Center if there is a change to my email account or I feel that my secure password has been breached. I agree not to hold Jaffe Costmetic Eyelid Center or any of its staff liable for network infractions beyond its control.

Please print all information clearly

Name ______________________________________________________ Date of Birth _____/_____/_________

Confidential Email Address____________________________________________________________________

Signature __________________________________________________________________________________

Date ______________________________________________________________________________________

Patient Portal website is https://www.doctorjaffe.com

More general information about our clinic and medical links/information are located there. You may also download a copy of the Comprehensive Patient Portal User Guide at our website. Upon signing this document, your signature on this form is your agreement to the Policy and Procedures for our Patient Portal.

Jaffe Cosmetic Eyelid Center5744 LBJ Freeway, Suite 180Dallas, TX 75240

Username __________________________________________________________________________________

Password __________________________________________________________________________________

HIPPA Authorization Form for Family Members/Friends

I, ___________________________________, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to:

Name(s): Relationship:

_________________________________ ____________________________________

_________________________________ ____________________________________

_________________________________ ____________________________________

Health Information to be disclosed: (Check all that apply):My complete health record (including but not limited to diagnosis, lab tests, prognosis,treatment and billing, for all conditions) ORMy complete health record, as above, with the exception of the following

information: (Check as appropriate)

Mental health recordsCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOther (please specify _________________________________________

__________________________________________________________

This health information may be used to enable the persons I authorize to know and understand my condition and my treatment or treatment options, for treatment or consultation, for claims payment purposes, or related reasons.

This authorization shall be effective until (Check one):

All past, present, and future periods, ORDate or event: ____________________________________________________

unless I revoke it. (NOTE: You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.)

______________________________________________Name of the Individual Giving this Authorization

______________________________________________ ____________________Signature of the Individual Giving this Authorization Date

Authorization to Leave a Voicemail

Please provide number(s) ONLY IF you approve us to leave DETAILED information related to the following, on you voicemail? __Test Results, labs medical issues __Billing questions __Scheduling issues

Primary (____)____________ Seconday (____)______________It is our practice to confrim all scheduled visits with a phone call or email. This will be done for all patients. Please notifu the receptionist if there is an urgent reason to not confirm your appointments.

Authorization to Send an Emaill Message

Pleas provide an email address below ONLY IF you approve us to send DETAILED information related to the following to your email: __Appointments __ Billing __ Test Results, diagnosis and procedures

Email addresss: _____________________________________________________

Authorization to Send a Text Message

Please provide a number ONLY IF you approve us to leave DETAILED information related to appointments, billing, test results, diagnosis and procedures in a text message.(____)_______________

By signing below, I understnad and agree to all stated and filled in above. I also understand my rights are protected by the Privacy Act (HIPAA) and that I may request a copy of this Act at any time. I have been given the opportunity to review, understand and consent to this practice’s Notice of Privacy Practices are written.

Name (PRINTED) ______________________________________________

Signature ______________________________________________________

Date __________________________________________________________