Dr. Allen L. Van Beek, MD,FACS
7373 France Ave. South, Edina, MN 55435
952-830-1028

Text Box: Thank you for choosing our office! In order to serve you properly, we need the following information. Please print. All information must be completed. All information will be confidential.

PATIENT INFORMATION Date ____________________________

Patient Name________________________________________________________Date of Birth

Address_____________________________________________________________City________________________ State__________ Zip___________

Home Telephone_________________________ Work Telephone___________________________ Cell Phone: _______________________________

Social Security Number____________________________________ Sex □ Male □ Female

Check appropriate box: □ Minor □ Single □ Married □ Divorced □ Widowed □ Separated

Patient’s employer ______________________________________________ Occupation __________________________________________________

Address _____________________________________________________ City ____________________________ State __________ Zip __________

Spouse or parent’s name __________________________________________________ Employer ___________________________________________

Address_______________________________________________________ City_______________________________ State________ Zip___________

Whom may we thank for referring you? ______________________________________________ Purpose of today’s visit ____________________

Primary Care Physician? _____________________ Clinic Name: __________________________ Address: __________________________________

→ Would you like a referral letter sent? Y N

Pharmacy ______________________________________________ Telephone: _________________________________________

Person to contact in case of emergency? _____________________________ Relationship to patient __________________Telephone ___________

Address____________________________________________________ City____________________________ State__________ Zip_______________

RESPONSIBLE PARTY

Name of person responsible for this account _____________________________________________ Birth Date _______________________

Relationship to patient __________________________________ Employer _________________________________________________

Address ____________________________City _____________________________________ State __________ Zip _________________

Home Phone_____________________________ Work Phone ________________________Cell Phone______________________________

INSURANCE INFORMATION

Worker’s Compensation? Y N Auto-Related? Y N Date of Injury/Onset:___________________________

Primary Insurance Carrier ______________________________________________________________________________________________________

Policyholder’s Name:_______________________________________________Relationship to patient___________________________________________

Policy #/Group #_____________________________ ID#_____________________________________________________________________________

Ins. Co. address _____________________________________________________ City_______________________State________ Zip_________________

Secondary Insurance Carrier ____________________________________________________________________________________________________

Policyholder’s Name:_______________________________________________Relationship to patient___________________________________________

Policy #/Group #_____________________________ ID#_____________________________________________________________________________

Ins. Co. address ____________________________________________________ City_______________________State_________ Zip_________________

RELEASE AND ASSIGNMENT:

I hereby authorize Plastic Surgery Specialists, P.A. to release to my insurance carrier or its designated representatives, as well as to any physician/organization who participates in my treatment for related diagnosis, any information including the diagnosis and records of my treatment rendered to me during the period of such medical and/or surgical care. I further consent to the photographing of myself and/or minor child for teaching and medical records for services provided. I fully understand that I am responsible for all charges incurred, regardless of insurance coverage. I also understand that if my account is considered past due, a finance charge of 1.5% per month (18 % annually) will be assessed