Cosmetic Patient Demographic Information

Reason For Visit

Referred By

Please check as many as apply.

drweider.com
realself.com
Facebook
Instagram
Yelp
Google
Bing
Yahoo
Former patient, friend or relative
Other

If Former patient, Friend, Relative or Other Referral Please Explain

Name*

Prefix First Middle Last Suffix

Email*

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

You may leave a message on my

home phone
cell phone
work phone

Sex

Female
Male

Date of Birth

Age

Please enter a number from 0 to 110.

SSN

Marital Status

Single
Married
Widowed
Divorced

Spouse Name

Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name

Emergency Contact Phone

Nearest relative not living with you

Nearest relative not living with you Phone

Name of Responsible Person for Minor

First Last

Relation to minor patient

Responsible Person Phone

Patient Medical History

Allergies

Any known medication allergies? If yes, list medication and allergic reaction:

Medical History

Please check the appropriate answer if you have or have had:

Medical History Other

If other please describe

Family History Mother's Side

Please check if yes

Diabetes
Heart disease Stomach/Intestinal disorders Bleeding disorders
Bone or joint problems
High blood pressure
Liver disease
Lung disorder
Emotional problems
Cancer

Family History Father's Side

Please check if yes

Diabetes
Heart disease Stomach/Intestinal disorders Bleeding disorders
Bone or joint problems
High blood pressure
Liver disease
Lung disorder
Emotional problems
Cancer

Do you smoke

yes
no

If you smoke, how many cigarettes/packs per day?

Please enter a number greater than or equal to 0.

Do you drink alcohol?

yes
no

If you drink alcohol, how much and how often

List Previous Hospitalizations or Surgeries and Date

Medications Taken Regularly

Including aspirin, birth control pills, herbal medications and/or dietary supplements

Have you ever had a blood transfusion?

yes
no

If female, date of your last menstrual period

Have you taken aspirin-containing drugs in the last two weeks?

yes
no

Release of Records

I give authorization for the following person(s) to receive and information pertaining to my medical treatment and care from the office of Laurence Weider, M.D. I understand that the office of Laurence Weider, M.D. cannot release information to anyone that I have not provided below. Please specify name and relationship.

Authorizations

Payment Agreement

PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED WITH NO EXCEPTION. I AUTHORIZE DIRECT PAYMENT OF MEDICAL BENEFITS TO BE MADE TO LAURENCE WEIDER, M.D. ON MY BEHALF FOR ANY SERVICES RENDERED TO ME. SOME SERVICES RENDERED BY LAURENCE WEIDER, M.D. MAY NOT BE COVERED BY MY INSURANCE. I UNDERSTAND IT IS MY RESPONSIBILITY FOR PAYMENT OF SUCH SERVICES REGARDLESS OF ANY INSURANCE COVERAGE I MAY HAVE. I AUTHORIZE DR. WEIDER TO FURNISH MY INSURANCE COMPANY(S) ANY RECORDS REQUESTED BY THEM.

I agree to payment for services

Acknowledgement of Review of Notice of Privacy Practices

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

I agree to the privacy practices

Financial Policy

The financial policy can be viewed here.

I agree to the financial policy.

Authorization of Release of Medical Photographs

The release agreement can be viewed here.

I agree to the authorization of photographs and/or videotapes.

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7777 Forest Lane Building B, Suite B-145
Dallas, TX 75230

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