Oregon Cosmetic and Reconstructive Clinic

New Patient Registration Form

Please fill out this form completely. The following information will help us in providing you the best medical care and treatment possible. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

Legal First Name * Preferred First Name Middle Initial Legal Last Name * Date of Birth * SSN * Gender * Mailing Address * City * State * Zip Code * Cell Phone * Home Phone Email Address * Can we leave a detailed message if we cannot reach you directly? If YES, which preferred method? Preferred Language Emergency Contact Name * Emergency Contact Number * Who is your Primary Care Provider (PCP)?

Responsible Party

Primary Insurance Name Policy ID Group ID Policy Holder's Name Policy Holder's DOB Policy Holder's SSN Patient Relationship to Policy Holder Is this a work related or car accident injury?

Secondary Insurance Information

Secondary Insurance Name Policy ID Group ID Policy Holder's Name Policy Holder's DOB Policy Holder's SSN Patient Relationship to Policy Holder

Medical History

Please list all medications you are currently taking (including over the counter and vitamins/supplements) * Please list any allergies * Please check all that apply * Type of Cancer Other

Social History

Do you smoke? * How many cigarettes per day? Any other forms of tobacco? List Do you drink alcohol? How often? Do you use any illicit drugs? List

Family History

Does anyone in your family (living or deceased) have the following:

Please check all that apply Other

Surgical History

Please select/list all surgeries:

Please check all that apply: Other Are there any medical tests or imaging studies such as mammogram, X-rays, MRI, nerve tests relevant to your visit with us? If so, what is the study and where was it performed?

Consent for Text Communication

I hereby provide my consent to Oregon Cosmetic and Reconstructive Clinic to communicate with me via text message (SMS) for purposes related to my medical care. By signing below, I acknowledge and agree to the following terms: Purpose of Communication: The Clinic may use text messaging to send me important information related to my care, including but not limited to: appointment reminders and confirmations surgical and post-operative instructions, billing and payment information test results, referrals, and other medical updates, and general health reminders. Voluntary Participation: Participation in text message communication is voluntary. I may withdraw my consent and opt-out at any time by notifying the Clinic or responding to any text message with the word "STOP." Privacy and Confidentiality: While the Clinic will take reasonable steps to ensure the privacy of text message communications, I understand that text messaging is not a completely secure form of communication. I accept the risks associated with potential privacy breaches when using text message for communication. The Clinic is not responsible for unauthorized access to text messages, such as those accessed by third parties in case of lost or stolen phones. Frequency of Messages: I understand that text messages will primarily relate to appointments, treatments, and other essential medical communications, but the frequency may vary depending on my care needs. Message Costs: I understand that standard text message rates may apply, and I am responsible for any charges or fees associated with receiving text messages from the Clinic. Update of Contact Information: I agree to promptly inform the Clinic if I change my phone number or opt for a different method of communication. Opting-Out: I understand that I can opt-out of receiving text messages at any time by replying "STOP" to any text message I receive, or by contacting the Clinic directly. By signing below, I confirm that I have read and understood the above consent, and I agree to receive text messages from Oregon Cosmetic and Reconstructive Clinic regarding my medical care. I understand that I can revoke this consent at any time.

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Financial Policy

If I would like the clinic to bill insurance, I understand that it is my responsibility to confirm that Dr. Jenq is in network prior to being seen and that an increase in cost due to being out of network will be my responsibility. -Payment (self pay, copays, coinsurance) is due by time of service. -Effective January 1, 2025, a credit card surcharge fee of 3% will be applied to all transactions. -If our physician is not in network with your insurance, we will file your claims for you if you assign benefits to our physician. If your insurance company does not pay within a reasonable time, you will be responsible for payment. -To avoid a late charge of $5 per billing cycle, your payment must be received within 30 days of the statement date. -A $30 fee will be assessed for returned checks. -Cancellations are required at least 24 hours prior to your appointment. There will be a $25 no show fee for late cancellations. Three no show appointments will result in discharge from our practice. -Occasionally, as an executive decision, billing costs may be waived to aid in the treatment of patients. This decision shall not be construed as an admission of negligence or substandard care, but only an assistance to facilitate patient care.

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HIPAA Consent

ACKNOWLEDGEMENT OF ?NOTICE OF PRIVACY PRACTICES? understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. A copy of our ?Notice of Privacy Practices? is made available at the receptionist desk. I understand that this information can and will be used to: 1. Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly; 2. Obtain payment from third party providers; 3. Conduct normal healthcare operations such as quality assessments and physician certifications. I understand that Oregon Cosmetic and Reconstructive Clinic has the right to change its Notice of Privacy Practices from time to time and that I may contact the organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions but if you agree than you are bound to abide by such restrictions.

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Photography consent

I hereby voluntarily grant permission to The OCRC to take and use photos of myself (patient) for purposes of treatment and monitoring progress. The OCRC will NOT post your pictures online or use them for purposes other than listed above. I further understand that no form of compensation shall become payable to me for the use of these photographs. I hereby release The OCRC and its agents from any and all claims and demands arising out of or in conjunction with the use of these photographs.

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Media Photo Consent

Consent Statement: I, the undersigned, hereby give my consent to Dr Tina Jenq and Oregon Cosmetic and Reconstructive Clinic PC to use photographs taken of me during my clinic visits for various forms of media, including but not limited to: Social media platforms (e.g., Facebook, Instagram, Twitter), Website content, Printed promotional materials, Newsletters. OCRC and Dr. Tina Jenq will make every effort to ensure that my identity is protected, including blocking jewelry and tattoos or piercings. However, I understand that once my image is shared on social media, it may be viewed and shared by others. Rights: I understand that I have the right to: Request to review the images before they are published. Withdraw my consent at any time by contacting OCRC. Request that my images be removed from social media or other promotional materials at any time. Release of Liability: I release Dr. Tina Jenq, Oregon Cosmetic and Reconstructive Clinic PC, and its employees from any claims, demands, and liabilities in connection with the use of my image. Signature: By signing below, I acknowledge that I have read and understood this consent form, and I voluntarily give my consent for my images to be used as described above.

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Telemedicine Consent

Telemedicine is the distribution of health-related services and information via electronic and telecommunication technologies, such as computers and mobile devices, to access and manage health care services remotely. Telemedicine may include technologies you use from home or that your doctor uses to improve or support health care services. Telemedicine allows out-of-office patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions. Examples of telemedicine include videoconferencing, teleconferencing, transmission of images, ehealth including patient portals, and remote monitoring of vital signs. The benefits of telemedicine include the following: Make health care accessible to people who live in rural or isolated communities. Provide long distance clinical care. Make services more readily available or convenient for people with limited mobility, time or transportation options. Obtain expertise of specialists. Improve communication and coordination of care among members of a health care team and patient. Provide support for self-management of health care. Quick and efficient medical evaluation and management. INSTRUCTIONS This document explains the purpose of telemedicine ? also known as ?telehealth? and referred herein, collectively, as ?telemedicine? ? and outlines the benefits and risks of telemedicine. It is important that you read the whole document carefully. Please initial each page. Doing so means you have read the page. Signing the consent agreement means that you agree to a telemedicine session with your doctor or one of the doctor?s assistants (i.e. nurse practitioner, physician assistant, etc.). GENERAL INFORMATION Telemedicine is the distribution of health-related services and information via electronic and telecommunication technologies, such as computers and mobile devices, to access and manage health care services remotely. Telemedicine may include technologies you use from home or that your doctor uses to improve or support health care services. Telemedicine allows out-of-office patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions. Examples of telemedicine include videoconferencing, teleconferencing, transmission of images, ehealth including patient portals, and remote monitoring of vital signs. ALTERNATIVE METHODS OF MEDICAL CARE BESIDES TELEMEDICINE In-person care is an alternative method of medical care to telemedicine. BENEFITS OF TELEMEDICINE The benefits of telemedicine include the following ? Make health care accessible to people who live in rural or isolated communities.Provide long distance clinical care. Make services more readily available or convenient for people with limited mobility, time or transportation options. Obtain expertise of specialists. Improve communication and coordination of care among members of a health care team and patient. Provide support for self-management of health care. Quick and efficient medical evaluation and management. RISKS OF TELEMEDICINE As with any medical care options, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to: Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and assistant(s); Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; Security protocols could fail, causing a potential breach of privacy and/or inadvertent disclosure of personal identifying information and/or protected health information; Lack of access to complete medical records may result in adverse drug interactions, allergic reactions or other judgment errors; Overuse of medical care; Unnecessary or overlapping care.

Options * Electronic signature * Date *