JAMES J. ROMANO, M.D.
C
O S M E T I C
S
U R G E R Y
126 Post Street . Suite 618. San Francisco . California . 94108 . 415.981.3911 .
www.jromano.com
P
ATIENT
R
EGISTRATION
F
ORM
P
LEASE PRINT ALL INFORMATION CLEARLY AND
L
EGIBLY
.
Legal Name:
Last Name
First Name
M.I.
What name do you prefer to be called?
Age:
Mailing Address:
City:
______________________________
State: ______
Zip Code:
Employer:
Occupation:
Employer Address:
Date of Birth:
/ /
Social Security Number:
- -
Driver License #_____________________ Issuing State:
Single
Married
Domestic Partner Kaiser ID # (if applicable):
Please identify your contact phone numbers in order of preference:
Primary Phone Number:
(________) ______________________ Home Work Cell Phone
Secondary Phone Number: (________) ______________________ Home Work Cell Phone
Additional Phone Number: (________) ______________________ Home Work Cell Phone
Email Address:
(your email address is not released to external sources)
I would like to receive appointment reminders via my email address I would like to receive your email newsletters via my email address
Please identify the name of the individual you would like to be contacted in the event of an emergency:
Name:
Relationship:
Phone:
I was referred to this office by:
a friend/family member please identify:
a physician please identify:
other
please identify:
internet source please specify search engine, specific website, etc.
______
CONSENT TO TREAT
I hereby present to this office on a voluntary basis for the purpose of obtaining examination and/or treatment. I
hereby grant this office and its providers the authority to examine, evaluate, render treatment, provide
recommendations, and/or order any examinations or tests necessary in the process of my examination and/or any
subsequent treatment. I understand that there are certain risks associated with any examination or treatment. I
understand that the practice of medicine is not an exact science and that there are no guarantees of the results and
that every individual may respond differently to a particular procedure and/or treatment regimen. I understand that
my authorization for treatment remains in effect until which time I notify this office and/or its providers of my
intent to discontinue treatment.
Patient
name
Date
