If you are coming in for a spa treatment or to see one of our nurses for a medical treatment, please arrive 15 minutes prior to your appointment.
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1 Welcome to Nayak Plastic Surgery and Avani Day Spa! We specialize in Facial Plastic Surgery, Skin Care, and Spa Treatments. Our cosmetic services include laser treatments, such as wrinkle reduction, age spots and hair removal; sclerotherapy, injectables such as Botox and Restylane; medical grade skin care products; in-office liposuction; and a variety of facial surgical procedures. Our spa services include facials, massages, body treatments, waxing and spray tanning. Dr. Nayak also performs certain insurance billable services including functional nasal surgery such as septoplasty, nasal fracture repair, and skin cancer reconstruction. If you are coming in for a consultation with Dr. Nayak, please expect to spend about an hour at our office. At your visit our staff will take a set of photos, which will be analyzed during your one-one consultation with Dr. Nayak. If you are coming in for a spa treatment or to see one of our nurses for a medical treatment, please arrive 15 minutes prior to your appointment. Lastly, if you like, we can also schedule a complimentary skin health analysis with one our esthetician & skin care specialists. To save you time, we encourage you to fill out your new patient paperwork prior to your visit. Please also bring any insurance cards and your driver s license, which we are required to photocopy to help fight identity theft. Please also bring any X-Ray films or reports with you if applicable. If you are interested in a surgical procedure or in a treatment involving an injectable filler, you should discontinue use of aspirin, ibuprofen (Motrin/Advil), Naprosyn (Alleve), vitamin E, Garlic, Ginger, Ginseng, St. John s Wort or Ginko two weeks prior to your desired surgery or procedure date. If you are taking one of the above medications under a doctor s care, you must first check with that doctor before discontinuing use. You may take Tylenol or Extra Strength Tylenol. If you are unsure whether a product is safe to take before a procedure, please call our office. Our fee for a cosmetic consultation with Dr. Nayak is $100, payable at your consultation. You may apply this amount toward any procedure, spa treatment, skin care product or other service we provide if purchased within 3 months of your appointment. If you need to change or cancel your appointment, please do so at least 48 hours before your appointment. Patients who fail to appear fortheir scheduled consultation with Dr. Nayak without at least 24 hours notice will be asked to pay their consultation fee in advance should they wish to reschedule for a later date. Our office staff is made up of bright, energetic professionals. They will be happy to answer any questions you may have before or after your visit. We look forward to meeting you! L. Mike Nayak, M.D. (314)
2 PATIENT REGISTRATION (please print) Patient Last Name First Name MI Date of Birth Age Social Security # Marital Status Street Address City State Zip Phone (H) (C) (W) Emergency Contact Name Phone Number How did you hear about us: If Patient Is Under The Age of 18, We Require Responsible Party DOB & SSN Primary Insurance ID#_ Group # Carrier SSN DOB Relationship Workers Compensation: Were You Injured On The Job? Secondary Insurance ID#_ Group# Carrier SSN DOB Relationship Date of Injury Workers Compensation Carrier Address Were You Injured In An Auto Accident? City/State/Zip Accident Date ALL PROFESSIONAL SERVICES ARE CHARGED TO THE PATIENT. THE PATIENT IS RESPONSIBLE FOR ALL FEES REGARDLESS OF INSURANCE COVERAGE. I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL. I HEREBY ASSIGN ALL MEDICAL AND SURGICAL BENEFITS TO INCLUDE MAJOR MEDICAL BENEFITS INCLUDING MEDICARE PRIVATE INSURANCE AND OTHER PLANS TO NAYAK PLASTIC SURGERY, P.C. I GIVE AUTHORIZATION TO RELEASE ANY INFORMATION TO MY INSURANCE COMPANY THAT IT MAY NEED. IMPORTANT: EFFECTIVE JULY 1, 2013, DR NAYAK WILL NO LONGER ACCEPT MEDICARE PAYMENTS. ALL NON-COSMETIC SERVICES ON MEDICARE PATIENTS WILL BE ON A FEE-FOR- SERVICE BASIS, AND NEITHER DR NAYAK NOR THE PATIENT MAY ATTEMPT TO COLLECT REIMBURSEMENT FROM MEDICARE. Patient s Signature (If 18 years or older) Parent/Guardian s Signature (If under 18 years) Date Date
3 Nayak Plastic Surgery Patient Health/Skin History Form Name Today s Date Date of Birth Age Sex Height Weight Primary Care Physician Referred by Procedures I would like to discuss with the doctor: Facial Rejuvenation: Necklift Facelift Eyelid Correction Forehead/Brow Lift Fat Transfer Nasal Surgery: Cosmetic Profile Surgery: Chin Implant Cheek Implant Facial/Neck Liposuction Ear Surgery: Reduce Prominence Reduce Earlobe Size Repair Torn Earlobe Skin Rejuvenation: Wrinkles Pigmentation/Age Spots Redness/Rosacea Broken Blood Vessels Roughness Scars Large pores Acne Acne Scarring Other Injectables Botox Juvederm Restylane Radiesse Sculptra Lip Augmentation Other Other Procedures: Hair removal Fractional Lasers Microlaser Peel Chemical peels Photofacials Body: Take Shape for Life Medical Weight Loss/Management Zeltiq CoolSculpting Fat Reduction Please indicate in your own words what concerns you: Have you ever had or used: yes no Retin A Chemical peels Microdermabrasion Laser, type Botox Restylane, Collagen, etc Silicone Accutane Herpes (or cold sore) medication Oral contraceptives Current skin care regimen: Cleanser Toner Scrub Exfoliator Sunscreen Moisturizer Other Sun exposure: Tanning Beds: Sunscreen: Past: Little Excessive Past: Little Excessive Never Occasional Daily Present: Little Excessive Present: Little Excessive
4 Sister(s) Brother(s) Mother's Side Father's Side Mother Father Yourself Review of Systems Please circle any symptoms below that you feel are affecting your health: Personal/Family Medical History Please check where you or members of your family, have had the following: General: Fatigue, unexplained weight gain/loss, fever, chills, night sweats, sleep problems, pain. Skin: New or changing skin growth, unexplained rash. Head: Headaches, recent trauma. Eyes: Blurred/loss of vision, eye pain, discharge, glasses/contacts, dryness, lasik, glaucoma Ears: Excessive noise exposure (loud music), ear pain, loss of hearing, ringing in ears, drainage. Nose: Frequent bloody nose, sinus pain, post nasal drainage, congestion. Mouth: Tooth pain, oral sores, bleeding. Throat: Hoarse voice, voice changes, pain or difficulty swallowing, frequent soreness or swelling. Neck: Pain, stiffness, swelling. Chest: Breast changes or lumps, nipple discharge, chest wall pain. Lungs: Cough, shortness of breath, wheezing. Heart: Murmurs, palpitations, pain with exertion, passing out. Stomach: Frequent nausea, vomiting, diarrhea, constipation, abdominal pain, bleeding, constipation. Urinary Tract: Frequent urination, pain on urination, blood in urine. Musculoskeletal: Joint pain, swelling, muscle pain, stiffness, restricted movement, swelling. Nervous System: Loss of consciousness, dizziness, seizures, weakness or numbness in any body part, tremors, twitching. Mental Health: Feelings of nervousness/anxiety/panic, crying spells, depression, confusion, problems concentrating. Blood/Lymph: Anemia, bleeding tendency, easy bruising, swollen/painful lymph nodes. Other: _ AIDS/HIV Alcoholism Anemia Anxiety Arthritis Asthma Bleeding Problem Cancer Cirrhosis Dementia Depression Diabetes Mellitus Eczema, Hives Rash Eye Problem/Glaucoma Heart Disease/Murmur Hemophilia High/Low Blood Pressure High Cholesterol Kidney/Bladder Problem Liver Disease/Jaundice Lung Disease Mental Illness Osteoporosis Parkinson s Disease Peptic Ulcer Disease Phlebitis/Blood Clot Rheumatic Fever Seizures/Epilepsy Sickle Cell Disease Stroke Thallasemia Thyroid Disease Tuberculosis Other:
5 Allergies: None Medication Allergies Reactions (ie, sulfa hives) Latex Other General/Social Information: Would you be able to lie on your back comfortably for 4 hours? No Yes Do you smoke? No Yes Cigarettes Cigars Pipe Other If yes, how much? How long? Are you a former smoker? No Yes If yes, when did you quit? Do you drink alcohol? No Yes If yes, how much and how often do you drink? per # of drinks (day, week, month or year) Exercise: how much/what kind? Have you ever used intravenous or recreational drugs? No Yes If yes, please list: Are you pregnant or nursing? No Yes With whom do you live? I live alone. I live with Are you currently: Single Married Widowed Divorced Separated Current occupation/employment: Retired Disabled Working as Who do you want notified in case of emergency? (Name) (relationship) (phone #) Please list all current medications Prescription Drugs: Name Dose Reason for taking it Over the counter: (aspirin, Tylenol, antihistamines, herbals, vitamins, etc) Name Dose Reason for taking it Please list current illnesses/health problems: Please list surgeries and hospitalizations: Year ALL PROFESSIONAL SERVICES ARE CHARGED TO THE PATIENT. THE PATIENT IS RESPONSIBLE FOR ALL FEES REGARDLESS OF INSURANCE COVERAGE. I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL. I HEREBY ASSIGN ALL MEDICAL AND SURGICAL BENEFITS, TO INCLUDE MAJOR MEDICAL BENEFITS INCLUDING MEDICARE, PRIVATE INSURANCE, AND OTHER PLANS TO NAYAK PLASTIC SURGERY, PC. I GIVE AUTHORIZATION TO RELEASE ANY INFORMATION TO MY INSURANCE COMPANY THAT IT MAY NEED. I, THE UNDERSIGNED, DO HEREBY GIVE MY CONSENT FOR NAYAK PLASTIC SURGERY, PC, TO FURNISH TREATMENT CONSIDERED NECESSARY, AND PROPER IN DIAGNOSING AND/OR TREATING MY PHYSICAL AND COSMETIC CONDITION(S). Patient Signature Form completed by Person other than patient Physician Signature Date Reviewed
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