Chief Complaint/Purpose of Visit:
Do you have children?? Y
Will you absolutely refuse blood transformation at any condition? Yes
Are your Imune System is UptoDate Yes
Are you currently being treated by a physician for any of the following? Please check the box if “Yes.”
Please explain any “Yes” answers at the bottom of this page
Blood in stool
Recent vision changes
Shortness of breath
Feet / leg swelling
Blood in urine
Lap Pap Smear
Number of pregnancies
Number of deliveries
Monthly self exams
Easy bleeding or bruising
HIV / AIDS
Hepatitis (A, B, or C?)
Rashes / dermatitis
Changes in moles
Last Prostate Exam (YR):
Last PSA Test (YR):
Testicular lumps, pain
Credit Card on File Policy
Please complete this form in its entirety. This form serves as confirmation that you are aware that Northstar Surgery Specialists P.A. has a policy that requires each patient to follow a payment plan with a credit card on file.
I,hereby consent to follow the payment agreement given below with strict abidance. Should I have any difficulty, I fully accept it as my responsibility to report this matter to Northstar Surgery Specialists before my next payment, so as to allow for alternate arrangements to be made.
This policy is in effect due to
the raise in patient deductibles and patient responsibility due to the change in health insurance policies and guidelines. If you have any questions about your coverage,
please contact your insurance company on the number listed on the back of your insurance card.
If surgery is required, a cost estimation will be provided to you prior to surgery upon request
The benefit of this form is that no cost will be collected up front prior to surgery. By signing below, this allows us to set you up on a payment plan
of $100/month for any and all charges incurred from office visits and operations. If you decline to put your card on file, you will be responsible for paying your
amount due in full PRIOR TO SERVICES, unless alternate payment arrangements have been agreed upon by
the billing administrator of NorthStar Surgery Specialists,P.A.
Date of Birth:
YOU WILL RECEIVE A CONFIRMATION EMAIL PRIOR TO ANYTHING BEING CHARGED ON YOUR CREDIT CARD
The below credit card will be used for any charge incurred from office visits/operations. This card will be set up for a payment plan of $100/month after insurance’s final determination unless otherwise specified (defaults to the 1st day of every month unless otherwise specified)
Date of Birth:
I decline to put my card on file, with the understanding that will be responsible for payment in FULL of any balance prior to any procedure performed/office visit.