Patient Fact Sheet - The Rose Clinic

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Kevin G. Rose M.D.
Name:________________________SS#______________________Date:____________
DOB____/____/____ Weight_____ Age _____ Ht.______ Gender:
Male
Female
Address:____________________________________ City:________________________
State:_______________ Zip code:______________ Home Phone#: (
)_____-______
Work #: (
)________-________
Ext: ______ Cell #: (
)_______-__________
E-mail:__________________________________________________________________
Place of employment:_____________________Insurance Co. name_________________
Emergency Contact # :(
) ______ -_______ Name:______________ Relation:___________
Do you have any known medical allergies?_____________________________________
Current Medications (Prescription, over-the-counter, or herbal supplements)
________________________________________________________________________
What will we be seeing you for/procedure of
interest?:_______________________________________________________________
Who is your Primary Care Physician or Referring Physician?______________________
Address:__________________________________Phone#:_______________________
I authorize The Rose Clinic to contact me, at the above number(s) and address(s) for
correspondence, messages or appointments. I understand I am responsible for my
account being paid in full. I agree that The Rose Clinic can add collection costs up to
50%, attorney’s fees, court costs and interest, at the rate of 1.5% per month to my
outstanding balance whether or not a lawsuit or arbitration is commenced.
Signature:_________________________________
Date:_____________
*
How did you hear about us?:_______________________________________________
Board Certified by the American Board of Plastic Surgery

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