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Dr. Allen  L. Van Beek, MD,FACS
7373 France Ave. South, Edina, MN 55435
952-830-1028
 

     Go To Health Screening Form

Text Box: Thank you for choosing our office!  In order to serve you properly, we need the following information.  Please print.  All information must be completed.  All information will be confidential.

PATIENT INFORMATION                                                                                                                                      Date ____________________________ 

 

Patient Name______________________________________________________________________________Date of Birth______________________

 

Address_____________________________________________________________City________________________ State__________ Zip___________

 

Home Telephone_________________________ Work Telephone___________________________ Cell Phone: _______________________________

 

Social Security Number____________________________________                       Sex                     Male                Female

 

Check appropriate box:                 Minor                    Single                 Married                 Divorced              Widowed           Separated

 

Patient’s employer ______________________________________________ Occupation __________________________________________________

 

Address _____________________________________________________ City ____________________________  State __________  Zip __________

 

Spouse or parent’s name __________________________________________________ Employer ___________________________________________

 

Address_______________________________________________________ City_______________________________ State________ Zip___________

 

Whom may we thank for referring you? ______________________________________________   Purpose of today’s visit ____________________

 

Primary Care Physician? _____________________  Clinic Name: __________________________ Address: __________________________________

 

→  Would you like a referral letter sent?      Y     N  

 

Pharmacy ______________________________________________               Telephone:   _________________________________________

 

Person to contact in case of emergency? _____________________________ Relationship to patient __________________Telephone ___________

 

Address____________________________________________________ City____________________________ State__________ Zip_______________

 

 

RESPONSIBLE PARTY

 

Name of person responsible for this account _____________________________________________ Birth Date _______________________

 

Relationship to patient __________________________________ Employer _________________________________________________

 

Address ____________________________City _____________________________________ State __________ Zip _________________

 

Home Phone_____________________________ Work Phone ________________________Cell Phone______________________________

 

 

INSURANCE INFORMATION

 

Worker’s Compensation?    Y      N                                      Auto-Related?   Y    N                             Date of Injury/Onset:___________________________

 

Primary Insurance Carrier ______________________________________________________________________________________________________

 

Policyholder’s Name:_______________________________________________Relationship to patient___________________________________________

 

Policy #/Group #_____________________________     ID#_____________________________________________________________________________

 

Ins. Co. address _____________________________________________________ City_______________________State________ Zip_________________

 

Secondary Insurance Carrier ____________________________________________________________________________________________________

 

Policyholder’s Name:_______________________________________________Relationship to patient___________________________________________

 

Policy #/Group #_____________________________     ID#_____________________________________________________________________________

 

Ins. Co. address ____________________________________________________ City_______________________State_________ Zip_________________

 

 

RELEASE AND ASSIGNMENT:

 

I hereby authorize Plastic Surgery Specialists, P.A. to release to my insurance carrier or its designated representatives, as well as to any physician/organization who participates in my treatment for related diagnosis, any information including the diagnosis and records of my treatment rendered to me during the period of such medical and/or surgical care.  I further consent to the photographing of myself and/or minor child for teaching and medical records for services provided.  I fully understand that I am responsible for all charges incurred, regardless of insurance coverage.  I also understand that if my account is considered past due, a finance charge of 1.5% per month (18 % annually) will be assessed

 

 

Patient’s Signature________________________________________Guarantor’s Signature_________________________________________________