Mike Majmundar, MD
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Our goal at MM Lift is to provide complete, compassionate and high-quality care that is centered around you. Please help us meet this goal by providing as much of the following information as possible.
Patient Information
First Name Middle Name Last Name
Sex
Date of Birth
 
Marital Status  
Address
City Zip Code State
Email ID*
Home Phone Cell Phone
Primary Care Physician Phone
Patient Employer
Job Title Work Phone
 
 
 
Emergency Contact
Person to contact Relationship to patient
Home Phone Work Phone
Cell Phone Other
 
 
 
Primary Insurance
Insured's Name Relationship to Patient
Insured's Address
Insured's Home Phone Date of Birth
Insurance Carrier Insured SS#
Policy# Group#
Effective Date
Employer of Policy Holder
 
 
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Mike Majmundar, MD
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Current Symptoms
Are you currently experiencing any of the following
Medical Illnesses
Diabetes High Blood Pressure
Blocked Arteries Heart Attack
Stroke Hepatitis B
Hepatitis C Emphysema/COPD
Chronic Bronchitis Heartburn
HIV Chest Pain
Bleeding Disorder Dry Eyes
Radiation/Chemotherapy Migraines
Seizures Depression
Anxiety Fever Blisters/Cold Sores
Asthma Stomach Ulcers
Hayfever Cancer, Type
Psychiatric Illness Other
Muscle disorder (e.g. Myasthenia Gravis)    
Other Surgery/Injuries/Illnesses
Surgery(Cosmetic & Non-cosmetic)   Injuries/Hospitalizations(accidents, fractures, lacerations)
Herbal Supplements  
Medications   Allergies/Medical Allergies
Aspirin ? Known Environmental Allergies
Social History
Tanning Bed Use   Alcohol Use
Do you smoke? Have you smoked in the past? When?
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Mike Majmundar, MD
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How did you hear about our practice?
   
        We would love to thank them      
 
E-mail address if not noted above
Discussion
What would you like to discuss with Dr. Majmundar today?
When do you plan to have your procedure?
Past Consultations
Have you seen another physician about these concerns?
When did you first consider plastic surgery?
Have you ever seen a psychiatrist? Why?
What are your concerns (choose all that apply)?
 
List of All Cosmetic Procedures
Please list all cosmetic procedures (including last Botox injection and last filler injection), the person who performed them & when they were performed.
 
 
 
 
 
 
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Mike Majmundar, MD
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Please complete for a Complimentary Skin Care Evaluation or any scheduled skin care treatment. We believe in having good, natural looking skin for life. As such, we offer complimentary skin care consultations to determine the best skin care options available for you. Just ask for a Complimentary Skin Care Evaluation when you schedule your appointment.
Are you currently having any of the following skin treatments?
   
 
 
Other Information
Have you seen a Dermatologist in the past year? If so, please list Dermatologist's name and reason for visit,
History of Skin Cancer? Where?
What is your Genetic/Ethnic Background?
Are you on birth control or hormone therapy?
Are you pregnant or breastfeeding?
What skin care products are you currently using?
What Skin Conditions do you want to improve?
 
Please check if you are presently using or have used in the past
 
 
 
 
 
I have acknowledged that all the information provided by me is true and correct to the best of my knowledge.

I understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). I understand that the treatment may involve risks from both known and unknown causes, and I freely assume these risks. Possible risks, though rare, can include mild swelling, mild redness, pigmentary changes and mild discomfort.
 
 
 
 
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Mike Majmundar, MD
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Financial Policy
1. All insurance Co-Payments are due at the time of service.
2.
A NO-SHOW fee of $50.00 may be assessed for each appointment missed. Notify us at least 24 hours in advance to cancel or reschedule your appointment to avoid the penalty.
3.
Payment is due at time of service for all in-office cosmetic procedures.
4.
Any dishonored check will result in a $35 return check charge.
5.
It is your responsibility to confirm our physicians participate in your insurance plan. If you see a physician that is not on your plan, you are responsible for all charges in full.
6.
All medical records requests must be in writing and received 72 hours prior to the date needed. All medical records request need to be in writing. There is a $25 search and find fee as well as a per page charge for coping your records in accordance to Georgia State law.
7.
We charge an administrative fee to cover the cost of certain administrative tasks such as completion of FMLA, disability, school forms as well as patient requested reports such as claims, statements, payment histories, and copies of medical record.
8.
If your balance becomes 60 days delinquent after insurance payments, your account may be sent to a collection agency. You are responsible for all collection fees incurred.
9.
Cosmetic Surgery Quote After you and Dr. Majmundar have finalized your surgical plan, we will provide you with a quote for your surgery. The quote is an estimate and will include your initial consultation, a pre-operative visit with Dr. Majmundar, digital photographs, a visit with Dr. Majmundar the morning of surgery to answer any questions, the procedure, all immediate post-operative visits, and all related follow-up visits for one year. We will also provide you with an estimate of the facility and anesthesia fee with your quote. All quotes are valid for 90 days.
10.
Non-Refundable Deposits. We collect a non-refundable deposit of $500 or half of the procedure quote, whichever is less, to schedule and hold your desired date of surgery. You may schedule your procedure as soon as the day of your initial consultation. A non-refundable deposit of $500 is also collected for any laser, skin tightening, or in-office liposuction procedure at the time of scheduling.
11.
Full payment for cosmetic surgery is due at our office at your preoperative appointment prior to surgery. If the procedure is performed at our surgery center, the facility and anesthesia fees will be collected at the same visit. If the procedure is scheduled at another facility, that facility will contact you directly for the appropriate facility and anesthesia fees prior to your procedure.
12.
Payment Options Cosmetic procedures are an excellent investment in your medical and psychological well-being. To make your healthcare investment cost-effective, we provide the following payment options.
  i) Cash or certified check.
  ii)
All major credit cards - VISA, MasterCard, Discover, American Express.
  iii)
CareCredit gives you convenient low monthly payment options so you can get the procedure you want now. This involves a simple one page application and immediate approval online. There are no up-front costs, no prepayment penalties and no annual fees. Learn More »
13.
Cancellation/Refund Policy If your scheduled surgery is re-scheduled within 7 days of your surgery date, you will be charged a $250 rescheduling fee. If your scheduled surgery is cancelled, at any time, for any reason, you will be refunded all monies less the $500 non-refundable deposit and a $50 administrative fee for refund processing. Cancelling any laser, skin tightening, or in-office liposuction procedure within 48 hours of your scheduled date, will forfeit your $500 deposit. There are no refunds on skin care products, Latisse, oxygenetix, or Neotensil products. Exchanges for these products are permitted. We understand that a situation may arise that could force you to reschedule or cancel on short notice, but please understand that this also effects your surgeon's schedule, staffing, and other patients as well.
14.
Additional charges Required lab work or additional operative time will be billed separately to you by the lab, surgery center, or hospital. We recommend that the patient be covered by health insurance at the time of the cosmetic surgery in the rare instance that a post- operative complication develops. All charges related to additional procedures for revisions or complications are the full responsibility of the patient.
 
       
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.
I acknowledge that I have received a copy of the office's Notice of Privacy Practices.
Electronic Patient Signature* Date
Consent for Photography
I authorize Dr. Majmundar and associates to photograph myself or patient and agree that the prints may be used for purposes indicated below. I understand that my name will not be used or disclosed in connection with the image.
 
 
 
By signing this, I release Dr. Majmundar and staff of MM Lift from all claims that may result from the taking and use of these photographs for the above named purpose(s).
 
 
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Checking is ok