Marc Zimbler MD FACS | Patient Registration

First Name:(Required)

Last Name:(Required)

Birth Date:(Required)

Age:(Required)

Gender:(Required)

Marital Status:(Required)

Address:(Required)

City:(Required)

State:(Required)

Zip Code:(Required)

Home Phone:(Required)

Cell Phone:(Required)

Email Address:(Required)

Emergency Contact:(Required)

Emergency Contact Phone Number:(Required)

Primary Physician Name:(Required)

Physician Contact Phone Number:(Required)

Pharmacy Name:(Required)

Pharmacy Contact Phone Number:(Required)

Who should we thank for referring you?(Required)

Purpose of Today’s Visit:(Required)

Occupation:(Required)

Company Name:(Required)

Medical Insurance Information

Primary Insurance:(Required)

Relationship of Insured to Guarantor:(Required)

Guarantor Name:(Required)

Payment Permission

I hereby authorize payment directly to Dr. Marc S. Zimbler for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by my insurance and for all services rendered on my behalf or my dependents.

I authorize Dr. Marc S. Zimbler and/or any provider or supplier of services in his office to release any information required to secure payment of benefits. I authorize the use of this signature on all insurance submissions.

Medical History Questionnaire

Place checks if you have any of the following medical conditions:

Place checks if you have any of the following medical conditions:(Required)

Place checks if you have any of the following medical conditions.

Past Surgical History

Have you used Botox or other facial fillers within the last 12 months:

History of facial cosmetic surgery (nose / eyelid / facelift):

History of functional nasal or sinus injury:

History of any other surgeries:

Past Surgical History(Required)

Allergies

Allergies to medications:

Allergies to adhesive tape:

Allergies to local anesthesia / Lidocaine:

Allergies or family history of allergy to general anesthesia:

Other allergies:

Allergies(Required)

Social History

Do you currently smoke or vape:

Have you ever smoked in the past:

Do you drink more than 2 alcoholic drinks per day:

Have you ever had a problem with alcohol dependence:

Have you ever had a problem with drug dependence:

Do you use any “recreational drugs” with frequency:

Do you use any weight loss medication such as Ozempic or Mounjaro:

Please list all medications: (include aspirin, birth control, vitamins, herbal or homeopathic medicines, weight loss medications such Ozempic and Mounjaro)

Medication 1:

Medication 2:

Medication 3:

Medication 4:

Medication 5:

Medication 6:

Medication 7:

Medication 8:

Notice of Privacy Practice Patient Acknowledgement(Required)

I have received and understand this practice’s Notice of Privacy Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practices legal duties with respect to my health information. All forms and policies referred to in this Notice of Privacy Practices are available at the reception desk and in the waiting room. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information it maintains. If changes occur, this practice will provide me a revised notice upon request.

Signature(Required)

CAPTCHA