New Patient Form

Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc.)

Collection of the following information is encouraged by federal health agencies. This information is used to monitor
and improve the quality of care provided to all patients.

Patient Financial Obligation Agreement

I understand that all applicable copayments and deductibles are due at the time of service. I understand that any outstanding statements past 90 days are subject to collection status and may incur additional charges I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to Adam J Cohen, MD for services rendered. I authorize representatives of Adam J Cohen, MD to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim.

Notice of Privacy Practices: Acknowledgement of Receipt

I acknowledge that I was provided with a copy of the Adam J Cohen, md Notice of Privacy Practices (NOPP).

Information Disclosure and Consent
Adam J Cohen, MD will provide you with the health plans that your provider accepts. If you decide to be treated by our provider and he does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider.

Have you EVER had any of the following:

Please list ALL of your current medications, including over the counter medications, supplements and herbs:

Review of Systems
Please indicate ALL that you have experiences in the last 6 – 12 months

Constitutional

Head, Eyes, Ears, Nose, and Throat

Cardiovascular

Respiratory

Neurological

Musculoskeletal

Genitourinary

Integumentary

Psychiatric

Hematologic/Lymphatic

Endocrine

Additional Ophthalmology Information

Chief Complaint: What is the main primary problem with your eye(s), eyelids or face, and when if you first notice
symptoms or were you told or your diagnosis?

Past History:

Do you have or have you had any of the following problems or conditions?
Please answer ALL questions – indicate YES or NO. If the answer is YES, please provide a brief explanation.

Do you ever take Aspirin, Plavix, Coumadin, Lovenox? YesNo

Problems tolerating anesthesia:

Family History:

In addition to our medical services, we also specialize in aesthetic/cosmetic and rejuvenation procedures of the face
and eyes. To ensure we are meeting our patient’s needs, we ask that you complete the following questionnaire.

Please check all that apply.

These are the areas of interest or concern to me:

Do we have your permission to send information via email/main or call you regarding the above
procedures and updates about our practice?

How did you hear about us (please specify)