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Amae Plastic Surgery

Patient Information

Thank you for choosing Âmae Plastic Surgery for your procedure. In an effort to provide the very best care to our patients and their families, we would appreciate it if you would spend a few minutes of your time completing this form. Thank you again for your comments.

Printable version of the form is also available: Patient Information

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*Patient Name:

Address:

City:

State:

Zip:

*Home Phone:

Cell Phone:

*Email:

Birthday:

Social Security #

Sex

Marital Status

Employer

Work Phone

Business Address

City:

State:

Zip:

Spouse or
Parent/ Guardian

Employer

Business Address

City:

State:

Zip:

Spouse/Guardian Work Phone

Spouse/Guardian Cell

Spouse/Guardian Other

If student, name of school/college

School City:

School State:

Referred By

Primary Care Physician (PCP)

PCP Phone

PCP Address:

PCP City:

PCP State:

PCP Zip:

Person to contact in case of emergency

Cell

Day

Other

Insurance Information

Name of Insured

Birthday:

Social Security #

Date Employed:

Current Employer

Employer Work Phone

Zip:

Insurance Company

Group #

Contract #

Insurance Address

City:

State:

Zip:

Deductible Amount

How Much Is Used?

Max Annual Benefit

Responsible Party

Person responsible
for this account

Relationship to Patient

Address

City:

State:

Zip:

Home Phone

Cell Phone

Email

Driver's License #

License State

License Birth Date:

Financial Instution

Employer

Work Phone

Is this person currently a patient of ours? Yes: No:

Additional Insurance

Do you have any additional insurance?

Yes:

No:

If yes, please complete the following:

Name of Insured

Relationship to Patient

Birthday:

Social Security Number

Name of Employer

Work Phone

Birthday:

Address

City:

State:

Zip:

Insurance Company

Group #

Contract #

Insurance Address

City:

State:

Zip:

Deductible Amount

How Much Is Used?

Max Annual Benefit

I authorize release of any information concerning my or my child's health care, advice and treatment provided for the purpose of evaluating administering claims for insurance benefits. I also hereby authorize payment of insurance payments otherwise payable to me to be paid directly to the doctor.

Signature of patient or parent or guardian if minor

Date

M.Azhar Ali, MD FACS
Âmae Plastic and Reconstructive Surgery
New Patient Medical Information

Patient		Physcian
Date		Age
Height		Weight
Cheif Complaint		Present Illness
Current Medications


CARDIOVASCULAR
Angina	Myocardial Infarction
Heart Failure	Stress Test	Date:
Pacemaker/AICD	Stents	Date:
Dysrhythmia	ECHO	Date:
Pacemaker/AICD	MVP/Valve Disease/Murmur
Hypertension	Other	Other:

PULMONARY
COPD/Emphysema	Smoking If Yes, Packs/Day:	Years Smoked:
Asthma/Bronchitis	Recent chest cold or sore throat
History of Tuberculosis	Sleep Apnea	CPAP:
Shortness of Breath	Other	Other:

NEUROLOGIC
Seizure Disorder	CVA or TIA
Sensory Motor Deficit	Parkinsons Disease
Multiple Sclerosis	Myasthenia Gravis
Gynecologic	Gravida: Para: Ab:
Other	Other:


ALLERGIES		HEPATIC
Latex		Cirrhosis/Hepatitis
Drugs		ETOH	Amount:
Food		Recreational drugs	Which
Dyes		Other
Other

RENAL		GASTROINTESINAL
Renal failure	HD: PD: Freq:	GERD/Hiatal Hernia
Altered Bladder Habits		Ulcers
Other		Recent History of diarrhea or constipation
		Other

ENDOCRINE		HEMATOLOGIC
Diabetes		Coagulopathy
Diet Controlled		History of blood thinners
Oral Hypoglycemic		Bleeding
Insulin		Other
Complications
Thyroid Disease
Other


MUSCULAR SKELETAL		Have You Had
Rheumatoid Arthritis		Skin Disease
Muscle Disorder		Cancer, if yes, date:
Back Pain/Injury		Radiation
Other		Chemotherapy
		A.I.D.S./HIV
		Other

Previous Surgeries

OPERATION	YEAR

How To Reach Us

Amae Plastic Surgery Center
Phone: 855-335-7200
43940 Woodward Avenue, Suite 100
Bloomfield Hills, MI 48302 | Map

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