Welcome and thank you for choosing Alicia CarroJl MD Ophthalmic Plastic & Reconstructive Surgery Center. We know you have many choices when it comes to your healthcare and we appreciate the trust you have put in us. Dr. Alicia CarroJl is a fellowship trained ophthalmic plastic and reconstructive surgeon that has the experience and expertise to perform medically-necessary surgical procedures on the eyes and face, as well as numerous surgical and non-surgical cosmetic procedures.

Dr. Carroll is one of only 12 physicians fellowship trained in oculoplastics the United States each year. What's more, she is the only female physician in the state of North Carolina that exclusively practices this sub-specialty. You can rest easy kno\-ving that you made the right choice for your ophthalmic plastic and reconstructive healthcare.

Some of the procedures performed at Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center include, but are not limited to:

Non-Surgical:

• Microdermabrasion • Facial fillers for wrinkles, including Botox® and Restylane® injections • Laser Skin Resurfacing

• Laser Hair Removal

• Chemical Peels • Aesthetic Facials

Surgical: • Cosmetic and medically necessary procedures on the eyes, including endoscopic

brow lifts, blepharoplasty and eyelid lifts • Removal of benign and malignant lesions, fuJI reconstruction of the face and

eyelids

• Treatment of eyelid and facial spasm • Repair of drooping eyelids as a result of normal aging and/or trauma

• Mid-face lift

Again, thank you for choosing Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center. We look forward to serving you!

--------

-----------------

2660 Tate Blvd. S.E., Ste. 200 Hickory, North Carolina 28602 828.267.2660 ph 828.267.2661 fax vlW\v.AliciaCarroIlMD.com

Date:

Patient Name:

Thank you for contacting Alicia Can'oll MD. We greatly appreciate your interest and look forward to meeting you and addressing your medical and/or cosmetic needs.

Enclosed, please find our new patient paperwork for you to complete (ink only) and do one of the following:

1- Bring with you to our office on the day of your appointment 2- Fax to our office 3- Mail to our office at the address listed above.

This will benefit you as it shortens your wait in our reception area prior to seeing Dr. Carroll.

OUR RECORDS INDICATE THAT YOUR APPOINTMENT IS SCHEDULED FOR:

______________________AT _

Please bring with you and have ready your INSURANCE CARDS and DRIVERS LICENSE for us to copy for your medical chart.

Sincerely,

The Staff of Alicia Carroll M.D.

----------- ---------------

2660 Tate Blvd. SE,Ste. 200 Hickory, NC 28602

828.267.2660 ph 828.267.2661 fax PATIENT INFORMATION

Patient Full Name: Today's Date: _

Chart #: Driver's License #:

Home Address: City State Zip _

Telephone: L-J Cell Phone: ~WorkPhone: {~ _

Email Address: _

Date of Birth: Age: Social Security Number: --,­

Marital Status: (circle one) Single Married Partnered Divorced Widowed Separated

Employer: Occupation__-----: ~--_=__----------Is this visit related to a worker's comp claim? (circle one) Yes No 1fso, Date ofAccident -'- _

Worker's Comp contact person: Phone: ~_

Emergency Contact Phone ~_- _ Family Doctor: Phone ~ _

Referring Doctor: Phone - __~-_----

How did you hear about Alicia Carroll l\1D? ~

Referred by: -'Purpose of Visit: _....;..... -----­

NameofPrima~InsuranceCompany _=__-~--------------__ Insured's Name: Date of Birth: --:-:--------­Social Security #: PolicylID #: ....;..... Group #: ~

Customer Service Phone Number: _

Secondary Insurance Company: _ PolicylID #: _ Group #: _ Insured's Name: PolicylID #: Group #: _ Customer Service Phone Number: _

Full Name: Relationship to Patient--:- _ Date ofBi11h: Social Security Number: ~ __=_:__­

Address: City State __--'-_.Zip__....;.....__~

Telephone: ( Employer: _

The notice ofPrivacy Practices and Patient's Rights at Alicia Carroll, MD Ophthalmic Plastic & ReconstruCtive Surgery Center has been given to me. I have read the policy and been given the opportunity to have my questions answered Therefore. I authorize the release ofany mecfical informat.ion. necessary to proces§. .clCJ.ims 4SSQ.c.ifJ.w..d withJJJy-_vis.iJs.1iLa4dWon. L _.. authorize payments for medical and/or surgical benefits to be paid directly to Alicia Carroll,MD Ophthalmic Plastic & Reconstructive Surgery Center. I understand the policy regarding filing ofmy insurance for 1"eimbursement, butknow that as a patient ofAlicia Carroll, MD, I assume a personal obligation and responsibility for my account.

Signature of Patient or Legal Guardian: Date: _

----------------- ----------- ---------

--------------

---------------

---------------------

---------------

--------------------------

2660 Tate Blvd. SE, Ste. 200 Hickory, NC 28602

828.267.2660 ph 828.267.2661 fax www.AliciaCarrollMD.com

Date: Date of Birth: Age: Name: Date last seen:

------------~--------- --------~-------Pharmacy Name: Pharmacy phone: _~ _ ~hief~omplainU~isto~: ~ ~

MEDICAL AND SOCIAL HISTORY

Medical History: do you have /have you had any of the following (if checked please indicate date)?

J Alcoholism 0 Healt Disease ~ Anemia / Blood Disease 0 High Blood Pressure ] Arthritis / Osteoporosis 0 Jaundice / ~epatitis disease -, , Bladder Problems 0 Kidney J Bowel Disorders 0 Migraines 'I Cancer 0 Respiratory (lung) disease ----: Breast Disease 0 Skin Disease .'

-, .J Diabetes 0 Thyroid Disease :J Depression 0 Ulcers J Epilepsy / Neuro Disease 0 Other :J Gall Bladder Disease

P S . IH'IS tory . / a : Date

ast urglca PIease 1st any surgerIes opera IOns you have h d Operation Date Operation

Social History ~abits: Smoking Y N

Alcohol Y N Drugs Y N Exercise Y N

Family History Do any family members (blood relatives) have the following (if yes, please indicate relationship to you)? ;] Alcoholism o ~eart Disease J Anemia / Blood Disease o ~igh Blood Pressure _ J Arthritis / Osteoporosis _ o Jaundice / Hepatitis disease _ j Bladder Problems _ o Kidney _

Bowel Disorders o Migraines _ ~----------

] ~ancer o Respiratory (lung) disease _ ;] Breast Disease o Skin Disease 'J Diabetes o Thyroid Disease _ J Depression _. _ o Ulcers

-~---------------:J Epilepsy / Neuro Disease _ o Other

-----------~------:::; Gall Bladder Disease ~

List Medications: List Allergies:

Signature: _

I

CONTRACTED CARE CONSENT AND AUTHORIZATION FORM

Patient: Responsible Party: _ Relationship: _ Consent for Routine Treatment: I hereby consent to the rendering of medical care, which may include routine diagnostic procedures and such medical treatment as my physician or others at Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center consider necessary. I understand that:

.. It is the policy of Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center that absent emergency or extraordinary circumstances, no substantial procedures are performed upon me unless and until I have an opportunity to discuss them with my physician or other healthcare professionals.

• I have the right to contest, or to refuse consent to any proposed procedure or therapeutic course. Payment: 1/ We agree to pay all charges for medical care rendered by Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center and it's physicians to me, my spouse, and/or minor children. .., T/We jointly and severally, guarantee full payment of all charges for medical care rendered by Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center and it's physicians to me, my spouse, and/or minor children, whether living with me or 110t. This is a guaranty of payment and not merely of collection, and I agree to be directly responsible for the payment of all charges incurred by these children. [f I/We fail to pay and such charges due to Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center and it becomes necessary for Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center to institute collection efforts against me/us, l/We agree to pay A[icia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center all cost of collection thereof, including reasonable attorney's fess incurred in the connection therewith.

Assignment of Insurance Benefits: j hereby authorize payment directly to Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center of medical or surgical benefits otherwise payable to me, including major medical insurance. I understand that I am financially responsible in the event medical or surgical benefits exceed the charges of Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center for its services in connection with the treatment rendered during this encounter. Any such excess amount may first be applied to paymel1t of any other indebtedness due by me or my legal dependents for other treatment rendered and the balance, if any remains, shall be paid to me.

Authorization for release of medical information: Alicia Carroll MD Ophthalmic Plastic & Reconstructive Surgery Center and/or my physician is authorized to furnish any medical information relating to treatment to my insurance company, health maintenance organization, preferred provider organization, alternative delivery system governmental or charitable agencies and their agents, my employer, and professional review organization with whom Thave an established relationship. I may revoke this authorization at any time, except to the extent that action has already been taken in reliance to this authorization prior to its revocation.

The notice ojPrivacy Practices and Patient's Rights at Alicia Carroll, MD Ophthalmic Plastic & Reconstructive Surgery Center has been given to me. J have read the policy and been given the opportunity to have my questions answered. Therejore, I authorize the release ojany medical information necessary to process claims associated with my visits. In addition, I authorize payments jor medical and/or surgical benefits to be paid directly to Alicia Carroll, MD Ophthalmic Plastic & Reconstructive Surgery Center. I understand the policy regardingfiling ojmy insurancejor reimbursement, but know that as a patient ofAlicia Carroll, MD, I assume a personal obligation and responsibility jor my account.

I have read and understand this authorization form, and agree to the provisions pertaining to my relationship with Alicia Carroll MO Ophthalmic Plastic &'Reconstructive Surgery Center.

Signature of Patient Signature of Witness Date

Signature of Guardian Signature of Witness Date

----------------- -------------

-------------

2660 Tate Blvd. SE, Hickory, NC 28602 828.267.2660 ph 828.267.2661 fax www.AliciaCarroIIMD.com

How May We Contact You?

Chart # _

Patient Name: Date of Birth

Sometimes it is necessary to communicate with your clients regarding appointments, instruction and other information about treatments received at our practice. Oftentimes, it is not possible to reach your personally. In the event that we are not able to speak with you directly, please give us instructions regarding the best way to communicate with you.

Please check all that apply and complete the necessary information:

o Messages may be left on my home answering system. The number is: _

o My answering machine does not identify me by name, but it is OK to leave message for me there anyway.

o Messages may be left for me at my work voicemail. The number is: _

o Messages may be left at home with my partner. Hislher name is: _

o Messages may be communicated to me via email. My email address is:

o Other persons authorized to receive messages on my behalf are:

Name Contact Info

Name Contact Info

I hereby release, discharge and agree to hold harmless all parties to whom the consent is given from any liability that may arise from the release of information to those authorized above. I understand that I may revoke this consent in writing at any time.

Patient Signature or Parent/Guardian Signature Date

Relationship to Patient if Minor

Dr. Alicia Carroll's Office (828) 267-2660

2660 Tate Blvd. S.E. Suite 200, Hickory, N.C. 28602

-cP Tate Blvd

w en PIEDMt. CARDIOLOGY >­to BUILDING

~ 2nd FLOO+"­to

C. E "0 to l: S0 C (,)

:lE

cfl Exit 126 Interstate 40

Catawba Valley 0<1J Medical Center

1stStW

"0 ­0:: .c: (,) " ­:::l

.c: () (1)

> 0 "­0).: to

u..

lb Exit 128

From Lenoir: 321 S to 1-40, 1-40 East to Exit 126, Top of ramp tum Left, onto McDonald Parkway. At 3rd traffic light turn Right, onto Tate Blvd. First building on Right. (Brick and Mirrored Glass Building across from Shurvvood Business Park)

From Charlotte: 321 N to 1-40, 1-40 East to Exit 126, Top of ramp turn Left, onto McDonald Parkway. At 3rd traffic light turn Right, onto Tate Blvd. First building on Right. (Brick and Mirrored Glass Building across from Shurvvood Business Park)

From Morganton: 1-40 East to Exit 126, Top of ramp turn Left, onto McDonald Parkway. At 3rd traffic light tum Right, onto Tate Blvd. First building on Right. (Brick and Mirrored Glass Building across from Shurwood Business Park)

From Winston Salem: 1-40 West to Exit 128, Top of ramp turn Right, At 4th traffic light turn Left, onto Tate Blvd /1 st Street West. Stay in the Left lane. Turn at the 3rd "Left turn only lane." Turn Left into our parking lot. (Brick and Mirrored Glass Building, on the Left, across from Shurwood Business Park)