J
AMES
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
I
NFORMATION
Last name _______________________ First name _______________________ M.I. ______
Age: _______
Address ________________________ City ______________________________ State______ Zip________
Employer (Name and Address)________________________________________________________________
Home phone (_____)______________Work phone (_____)______________ Cell phone (_____)____________
SSN#___________________ If you are a Kaiser patient, please give your ID #_________________________
Birthdate _______________ Driver License #___________________ Married____ Single____ Divorced
E-mail address ____________________________________
In Case of Emergency Contact: _______________________________________ Phone #: _____________
***** Please print full name and address *****
Referred by: _____________________________________________________________________________
Primary physician: ________________________________________________________________________
Ob-Gyn: ________________________________________________________________________________
Dermatologist: ___________________________________________________________________________
F EE IN FORM A TION
H ospital, a ne sthesia supplie s, anesthe siologist, a nd ope ra ting room fe e s ar e c omple te ly se parate fr om Dr . Romano's f e es.
I nsur a nc e c ompa nie s do not c ove r cosme tic proc edur e s. Plea se do not submit the se char ges or a sk us to f ile the se cha rges for
you. A deposit of $1000.00 must be paid in advance bef ore surge ry c a n be sc he duled. T he re ma ining ba la nce of sur ger y f ee s
is due a t the time of your pre ope ra tive visit. We ac ce pt Visa, Ma ster Car d, pe rsona l c he cks a nd ca shier 's chec k. W e pr e fe r
you not pa y in c ash. T he de posit is not re funde d f or a ny sur ge ry ca nc e le d a fter the pre ope ra tive visit. A fter the sur ge r y is
schedule d, $500 is c har ge d to c ha nge the da te of the pr oce dur e.
Signa tur e _______________________________________________
D ate ___________________________
FINANCIAL UNDERSTANDING
I understand I am financially responsible for the total fees for services rendered. Payment in full is expected prior to
service. A fee for returned checks is $35.00. Should my account go to an attorney, I will be responsible for all reasonable
and customary attorney's fees.
Signature ______________________________________________
Date ___________________________
