Kami Parsa, M.D.
465 N. Roxbury Drive, Suite 1001, Beverly Hills, CA 90210
Date: _________________________________
Name: ________________________________________________ Age: _____________ DOB: _______/______/______
Address: ______________________________________City_______________________State_______ Zip________________ Home Tel: ________________________________Cell:______________________________Wk Tel: _____________________ Email: _________________________________________ SS# _____________________________________ Primary Physician: _____________________________________ Phone #_________________________________________
How did you hear about Dr. Parsa ?_________________________________________________________________________
Have you been to our website?______________ Was our website helpful? No Yes If No, pls. list reason:
______________________________________________________________________________________________________
Is it ok to send mail to your address: No Yes Email Blast: No Yes Leave messages on #‟s above: No Yes
What is the reason for your visit today? (Circle all applicable procedures below)
Cosmetic Functional
Please describe your visit for today: ________________________________________________________________________
_____________________________________________________________________________________________________
Have you consulted with other physicians about procedure(s) indicated above: No Yes
If Yes, please describe your understanding of the procedure(s)____________________________________________________
Is this procedure a revision from a previous surgery No Yes If yes, how many previous surgeries?_____________________
What is your “ideal time frame” for procedure(s) completion _______________________________________________________
Employer _______________________ Address ______________________________________________________________ Occupation: _____________________________________________ Marital Status: _________________________________ Primary Insurance Co. ____________________________________ Policy # ______________________________________
Group # _______________ Name of person insured __________________________________ SS# ____________________ Eligibility Phone # _________________________________________ Copay ______________________________________ Secondary Insurance Co. ____________________________________ Policy # ____________________________________ Group # _______________ Name of person insured __________________________________ SS# ____________________
Eligibility Phone # _________________________________________ Copay _______________________________________
HEALTH INFORMATON
Do you have any chronic medical problems? (Circle all that apply)
Is there a personal or family history of anesthetic complications? No Yes
If yes, please explain_____________________________________________________________________________________
Do you have a family history of any medical problems? (Circle all that apply) Please indicate family member.
1._________________________________________
2. ________________________________________
3. ________________________________________
4. ________________________________________
5. ________________________________________
Please list all prior Hospitalizations:
1._________________________________________
2. ________________________________________
3. ________________________________________
4. ________________________________________
5. ________________________________________
Please list ALL medications and/or dietary supplements including: (Prescriptions, Over the Counter Medicines, Aspirin, Vitamins and Herbal Supplements such as Fish Oil, Saw Palmetto, Flax Seed Oil and St. John’s Wort)
1. _____________________________________________
6. _____________________________________________
2. _____________________________________________
7. _____________________________________________
3. _____________________________________________
8. _____________________________________________
4. _____________________________________________
9. _____________________________________________
5. _____________________________________________
10. ____________________________________________
Please list ALL allergies and describe reactions: (i.e. Shellfish, Latex, Penicillin, etc). 1. _____________________________________________
4. _____________________________________________
2. _____________________________________________
5. _____________________________________________
3. _____________________________________________
6. _____________________________________________
Social History: Have you ever used tobacco products? No Yes If yes, how long?__________ how much?__________
Which tobacco product(s) have you used?____________________________
If you are a former smoker, state the year you stopped: __________________ Past or current use of Nicotine Gum, Patch, or any other type of stop-smoking aid: No Yes
If yes, please list: _______________________________________________________________________________________ Alcohol Consumption:
_________Never (Do not consume alcohol) ________ Rare (1-2 drinks a week) _________ Moderate (7-10 drinks a week) _______ Heavy (daily or more than 10 drinks a wk)
Did you ever drink heavily in the past? No Yes Are you feeling hopeless about the present/future? No Yes Do you currently have thoughts of harming yourself? No Yes
Review of Systems: Please answer the following Yes or No questions to the best of your ability. Do you have any of the following conditions, illnesses or symptoms?
Shortness of Breath at night Y ___ N ____
Shortness of Breath on exertion Y ___ N ____
If Female, could you be preg? Y ___ N ____
Number of live births_______________________
Number of pregnancies ____________________
Date of last mammogram ___________________ Date of date of menses (period)______________
ASSIGNMENT AND RELEASE I, the undersigned, have insurance coverage with _________________________________________ and assign directly to Kami Parsa, M.D., Professional Corporation, all Medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or
not paid by insurance. If the nature of the disability be such that it is not covered by insurance, I will be responsible to the doctor for payment of the entire bill. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance
submissions. _________________________________________________________
_________________________________________________________
Ha a „Mérleg” közöl egy írást, alighanem azt akarja, hogy tanuljunk belőle. Ennek feltétele, hogy megértsük. Nem kevés fáradságot kívánt tőlem Karl-Heinz Menke „Napjaink krisztológiája – áttekintés” c. tanulmánya (2001/3). Nem tudom, mennyire sikerült megértenem, de nem szeretném, ha hozzászólás nélkül maradna ez az igényes áttekintés. Négy fejezetből á
I cambiamenti della struttura di mercato sono il risultato dei Quale è la struttura di mercato che genera i maggiori processi di entrata ed uscita, che possono essere dovuti all’effetto di strategie anticompetitive, alla differenziazione del prodotto, alle strategie di prezzo, alle restrizioni La R&S è maggiore tra imprese in concorrenza fra loro, di dimensioni relativamente più picc