As Soon As You Book For Your Procedure. Please Give My Rooms a Ring and My Friendly Staff Will Arrange a Consultation
|
|
- Aubrey Marshall
- 8 years ago
- Views:
Transcription
1 Dr. Adel Tanious FANZCA Specialist Anaesthetist Provider No: T Ph: Fax: PO Box 54 Introduction and Information about Fasting Instruction and Anaesthetic Fees Dear Patient Firstly I would like to introduce myself. My name is Dr. Adel Tanious and I will be your anaesthetist for your forthcoming. I strongly believe that I need to have a better understanding of your health condition to be able to ensure a safe and comfortable anaesthetic. I therefore need to communicate with you in order to minimise the chance of delaying or postponing the procedures. As Soon As You Book For Your Procedure Please Give My Rooms a Ring and My Friendly Staff Will Arrange a Consultation Phone no.: Office Hours Tuesday Friday 9.00am 3.00pm My rooms are located at 127 Torquay Road, Scarness - Hervey Bay Fasting Instructions: - For a Morning Operation: - No food after midnight but clear fluids (water, apple juice, black coffee or tea) may be consumed until 4 hours before the. For an Afternoon Operation: - You can have a light breakfast as long as it is 6 hours before the Eg. White Toast and Spreads. But clear fluids (water, apple juice, black coffee or tea) may be consumed until 4 hours before the. Medication and condition:- It is very important to notify me if you are a diabetic or on any blood thinning medication: eg. Aspirin, Clopidogrel (Iscover/Plavix), Asasantin or Warfarin 1
2 Anaesthetic Fees: - Please read carefully, complete and post the Financial Consent attached Anaesthetic fees are calculated according to time and complexity. Therefore, we can only provide you with an estimated cost of the anaesthetic prior to the actual. A personalised account will be sent to you after we receive your booking. You are kindly requested to pay this estimated fee PRIOR to your. All DVA and Work Cover patient accounts will be submitted directly to their respective health insurer. All other patients will be charged the estimated fees prior to the. Your personal out-ofpocket contribution will be influenced by your insurance. Self Funded Patients: All Self funded patients will need to pay the full estimated fee prior to the. After your another invoice will be sent to you. Once it is paid in full, you will receive a final receipt enabling you to claim your rebate from Medicare. Health Funds accepting Co-Payment (E.g. MBP, BUPA, AHSA group) This co-payment is very beneficial as it maximises the health fund rebate and minimises the patient s out-of-pocket contribution. If you are a member of one of these health funds you will only be required to pay the co-payment prior to the procedure. After the procedure another invoice will be sent directly to your health fund. This co-payment will vary depending on the time and complexity of the procedure and may range from $50 to $400. In case of Teeth extraction, your out-of-pocket contribution is $250-$350 for all major Health Funds. Health Funds not accepting Co-Payment (E.g. NIB, HBA, HCF, MU) However, if your health fund does not accept a co-payment you will need to pay the full estimated fee prior to the. This may range from $395 - $650 for a minor and $655 - $1500 for a major. After your another invoice will be sent to you. Once it is paid in full, you will receive a receipt enabling you to claim your rebate from Medicare and your Health Fund. Please note: in the majority of cases the estimated fees closely approximate the final one Your out-of-pocket and non-refundable contribution will be higher due to your health fund paying you less. This contribution may range from $200 for a minor to $700 for a major. In case of Teeth extraction your full fee is. The following is an example only. Health Funds accepting Co- Payment Health Funds not accepting Co-Payment Self Funded Patients Time Operation Anaesthetic Fees Teeth teeth teeth To be paid Prior to To be paid Prior to Out-Of-Pocket Contribution $250-$350 To be paid prior to About $360 About $0 I hope this guide is useful to you. If you have any further questions please phone my rooms on Our office hours are 9:00 AM to 3:00 PM from Tuesday to Friday. you can phone Monday to Friday from 9:00 AM to 5:00 PM. 2
3 PRE-OPERATIVE ASSESSMENT QUESTIONNAIRE Dr. Adel Tanious Patient Name: Date of Birth: Address: Suburb/City: State: Post code: Phone Nos: Home: Work: Mobile: Your GP Name & Phone No: Name Of Operation: Date Of Operation: Surgeon: Hospital: Medicare No: Ref No: Name and Number of Private Health Fund: Address: Emergency Contact Name and Phone Number: 1. List ALL MEDICATIONS you are currently taking (including over the counter, herbal/alternative medicines and/or pain killer). State dosage and strength. 2. List previous s including approximate dates. Yes No 3. Have you, or a relative had any complications with an anaesthetic or s? If yes, give details 4. Do you have any allergies to medications, latex, rubber and/or tropical fruits? If yes please list. 5. Do you currently have, or ever had, any of the following conditions? (Circle the specific condition and/or mark the applicable box with x) Angina/Coronary Disease/Heart Attack/Cardiac Surgery/Pacemaker Rheumatic Fever/Heart Murmurs/Palpitations High Blood Pressure Asthma/Chronic Bronchitis/Emphysema/Tuberculosis Other Lung Disease Sleep Apnoea Cough, Cold or Flu in the past 3 weeks Blood Clot in the Legs or Lungs (Thrombosis or Embolism) Blood Disease/Bleeding, Bruising problems/haemophilia/anaemia Have you Taken Aspirin/Warfarin within the past 5 days Please see the back Continue Question No. 5 3 Please Turn The Page
4 Stroke/Blackouts/Fits/Epilepsy Mental Health Condition eg. Depression, Schizophrenia Heartburn/Gastric Reflux/Hiatus Hernia/Peptic or Duodenal Ulcer Bowel Problems eg. Diverticulitis, Crohn s Hepatitis/Jaundice/Liver Disease Yes No Diabetes (Please circle treatment) Insulin / Tablets / Diet Have you recently taken Steroid (Cortisone/Prednisone) medication? Do you take Hormone replacement therapy? If yes, please list Arthritis/ Muscles Disease Do you have difficulty walking up a flight of stairs or 1 Kilometre? Any inherited disorder. (eg. Porphyria, Haemochromatosis, Thalassemia)_ Kidney/Bladder problems Are you pregnant? Do you get Motion sickness? Have you been overseas within the last 2 weeks? Do you smoke? If yes, How many per day Have you ever smoked? If yes, when did you cease? Do you use recreation drugs? If yes, which drug(s) and how often Do you consume Alcohol? If yes, how often Daily Weekly Monthly How much? Do you wear or have any of the following: (please circle) Hearing Aid Contact Lenses Denture Loose Teeth Dental Bridges Crowns Caps Artificial Eye Other Prostheses Have you lost weight recently without trying? If yes, how much Have you been eating poorly because of a decreased appetite? Are there any other health problems of which your Anaesthetist should be aware? If Yes, Please List Your Weight Your Height The information I have supplied in this questionnaire is accurate to the best of my knowledge. Patient Name: Sign: Date: If you have any inquiries, please ring the practice on or It is helpful to your Anaesthetist to have this information well in advance. 4
5 Patient Financial Consent Dr. Adel Tanious FANZCA Specialist Anaesthetist Provider No: T Ph: Fax: PO. Box 54 Patient Name: Phone no: Mobile no: Operation Date: I understand the costs are an estimate and may be subject to variation. I acknowledge that it is my responsibility to confirm with my health insurance fund the level of cover that I have and any amount that it will be my responsibility to pay. I understand that this document is not consent to, nor a request for, a procedure. Patient or Guardian s signature: Date: Patient or Guardian s full name: Please sign this Financial Consent and attach it with the Pre-Operative Assessment Questionnaire and You can either Post it to: Dr. Adel Tanious PO Box 54 Fax it to: it to: admin@anacare.com.au Drop it in to: 127 Torquay Road, Scarness QLD 4655 Office hours: Tue-Fri 9am-3pm 5
As Soon As You Book For Your Procedure. Please Give My Rooms a Ring and My Friendly Staff Will Arrange a Consultation
Dr. Adel Tanious FANZCA Specialist Anaesthetist Provider No: 2477954T Ph: 07 4128 2550 Fax: 07 4124 0496 admin@anacare.com.au www.anacare.com.au PO. Box 54 Introduction and Information about Fasting Instruction
More informationYOU AND YOUR ANAESTHETIC
YOU AND YOUR ANAESTHETIC Information Leaflet Your Health. Our Priority. Page 2 of 8 This leaflet aims to answer some of the questions you may have about your anaesthetic and contains fasting instructions.
More informationDENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
More informationGalerie Dental Care. Patient Information. Emergency Contact Relationship: Phone:
Galerie Dental Care Patient Information Date: Patient Name: Last First Middle Initial (Preferred Name) Gender: Birth Date: Marital/Family Status Address: Street Apartment # City Province Postal Code Phone
More informationMICHAEL D BROOKS, DMD, MS, PLLC MICHAEL J BOWMAN, DDS, MS, PLLC PATIENT INFORMATION RECORD DENTAL INSURANCE
PATIENT INFORMATION RECORD NAME DATE DATE OF BIRTH SEX SOCIAL SECURITY HOME ADDRESS HOME PH EMAIL CITY STATE ZIP EMPLOYER OTHER PH DENTAL INSURANCE PRIMARY SUBSCRIBER NAME SOCIAL SECURITY # DATE OF BIRTH
More informationX-Plain Preparing For Surgery Reference Summary
X-Plain Preparing For Surgery Reference Summary Introduction More than 25 million surgical procedures are performed each year in the US. This reference summary will help you prepare for surgery. By understanding
More informationOtis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology 2310 Myron Drive Raleigh, North Carolina 27607 P: (919) 782-9536 F: (855) 787-8025 Name: SSN: Date of Birth (mmddyy):
More informationLocal anaesthesia for your eye operation
Local anaesthesia for your eye operation Information for patients and families. www.anaesthesia.ie 1 This information leaflet is for anyone expecting to have an eye operation with a local anaesthetic.
More informationVaginal Repair- with Mesh A. Interpreter / cultural needs B. Condition and treatment C. Risks of a vaginal repair- with mesh
The State of Queensland (Queensland Health), 2011 Permission to reproduce should be sought from ip_officer@health.qld.gov.au DO NOT WRITE IN THIS BINDING MARGIN v2.00-03/2011 SW9226 Facility: A. Interpreter
More informationLast Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
More informationHow To Fill Out A Health Declaration
The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
More informationEnhanced recovery after laparoscopic surgery (ERALS) programme: patient information and advice 2
This booklet is funded by, and developed in collaboration between University Hospital Southampton NHS Foundation Trust and Pfizer Limited. NPKAM0198 March 2014 Enhanced recovery after laparoscopic surgery
More informationRoswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
More informationIf you have any questions or concerns about your illness or your treatment, please contact your medical team.
This booklet is designed to give you information about your operation. We hope it will answer some of the questions that you or those who care for you may have at this time. This booklet is not meant to
More informationAcknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
More information! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER
More informationEASTERN CONNECTICUT REHABILITATION CENTERS PHYSICAL THERAPY INFORMATION PACKET
EASTERN CONNECTICUT REHABILITATION CENTERS PHYSICAL THERAPY INFORMATION PACKET THANK YOU FOR CHOOSING ECRC-PT THIS PACKET INCLUDES IMPORTANT INFORMATION TO ASSIST IN YOUR RECOVERY AND UNDERSTANDING ABOUT
More informationAccount Payment Details
date / / title Mrs Miss Ms Mr Mast Dr family name given name address date of birth email phone h w m medicare number exp Medicare Reference Number (Small Number in front of your name) SMS message reminder:
More informationMyelogram PROCEDURAL CONSENT FORM. A. Interpreter / cultural needs. B. Procedure. C. Risks of the procedure
DO NOT WRITE IN THIS BINDING MARGIN v5.00-03/2011 SW9263 Facility: A. Interpreter / cultural needs An Interpreter Service is required? Yes No If Yes, is a qualified Interpreter present? Yes No A Cultural
More informationRekindling House Dual Diagnosis Specialist
Rekindling House Dual Diagnosis Specialist Tel: 01582 456 556 APPLICATION FOR TREATMENT Application Form / Comprehensive Assessment Form Please provide as much detail as you can it will help us process
More informationLaparoscopic Hysterectomy
Any further questions? Please contact the matron for Women s Health on 020 7288 5161 (answerphone) Monday - Thursday 9am - 5pm. For more information: Royal College of Obstetrics and Gynaecology Recovering
More informationIf you have any questions or concerns about your illness or your treatment, please contact your medical team.
This booklet is designed to give you information about your operation. We hope it will answer some of the questions that you or those who care for you may have at this time. This booklet is not meant to
More informationNEW PATIENT REGISTRATION
Title Mr / Mrs / Ms / Miss / Master / Dr Surname Given Names Address Postcode. Date of Birth. Age Occupation Telephone H.. M. W.. Next of Kin:. Tel:.. Referring Dr. Address.. Private Insurance YES / NO
More informationStanislaw Facial Plastic Surgery Center LLC Paul Stanislaw Jr., M.D.
Patient Information Stanislaw Facial Plastic Surgery Center LLC Paul Stanislaw Jr., M.D. Patient Name Date of Birth Age Address Marital Status Sex Address Home ( ) City State Zip Cell ( ) Employer Work
More informationVenous Thrombosis and Pulmonary Embolism Treatment with Rivaroxaban
Venous Thrombosis and Pulmonary Embolism Treatment with Rivaroxaban Information for patients and families Read this booklet to learn: about venous thrombosis and pulmonary embolism how the medicine Rivaroxaban
More informationPLEASE COMPLETE THE ENCLOSED PAGES AND RETURN TO THE RECEPTIONIST AT YOUR APPOINTMENT
NEW PATIENT PACK Dr Jehan Titus Dr Jimmy Lam (Please circle which Dr you will be seeing) PLEASE COMPLETE THE ENCLOSED PAGES AND RETURN TO THE RECEPTIONIST AT YOUR APPOINTMENT Please contact our rooms if
More informationQuestions Concerning Activities of Daily Living (ADL)
Questions Concerning Activities of Daily Living (ADL) Please fill out this form carefully and mark only one box for each question. 1. How well can you perform personal self care activities including washing,
More informationBorgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS
Borgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS Please complete the following form by filling in the blanks or by circling the answer provided. Last Name: First Name M.I. Address: City, State,
More informationNew Patient Registration Form
New Patient Registration Form Welcome to Bayside Dental Care! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
More informationPhysician address. Physician phone
PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center www.michigansportsmedicine.com Your family physician
More informationWhere are we located?
Patient Information 127 Frost Road, Salisbury South SA 5106 PO Box 515, Salisbury South DC SA 5106 P (08) 8250 7979 F (08) 8281 8048 E bookings@northernendoscopy.com.au W www.northernendoscopy.com.au Where
More informationPATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:
Anthony N. Dardano, D.O., P.A., F.A.C.S. AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY Diplomate of the American Board of Plastic Surgery Diplomate of the American Board of Surgery 951 N.W. 13 th Street,
More informationSlEEvE GASTRECTomY SURGERY What is a sleeve gastrectomy operation? BARIATRIC SURGERY
Sleeve gastrectomy surgery This leaflet gives you general information about your surgery. Please read carefully. Share the information with your partner and family (if you wish) so that they are able to
More informationWorkman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
More informationPatient Demographics Sheet
Patient Demographics Sheet PLEASE PROVIDE YOUR PHARMACY INFORMATION BELOW: PREFERRED PHARMACY: PHARMACY LOCATION: PHARMACY PHONE NUMBER: FOR OFFICE USE ONLY Dr. Goldblatt Dr. Brown Last Name: First Name:
More information1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
More informationGASTRIC BYPASS SURGERY
GASTRIC BYPASS SURGERY This leaflet gives you general information about your surgery. Please read it carefully. Share the information with your partner and family (if you wish) so that they are able to
More informationALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province:
More informationBefore and After Your Cardioversion
2013 Before and After Your Cardioversion Before and After Your Cardioversion Preparing for your cardioversion Your doctor has recommended cardioversion to treat your heart rhythm problem. This booklet
More informationSurgical Patient Information
Surgical Patient Information Joondalup Health Campus 1 Contents Our commitment to you Page 4 About your hospital stay Page 4 Admission and fasting Page 5 Day of admission Page 5 Leaving hospital Page 6
More informationPatient Information. Patient Diary for Gynaecological Laparoscopic Surgery on the Enhanced Recovery Programme. Here to help. Respond Deliver & Enable
Here to help Our Health Information Centre (HIC) provides advice and information on a wide range of health-related topics. We also offer: Services for people with disabilities. Information in large print,
More informationGASTRIC BYPASS SURGERY
GASTRIC BYPASS SURGERY This leaflet gives you general information about your surgery. Please read it carefully. Share the information with your partner and family (if you wish) so that they are able to
More informationCATARACT SURGERY. Date of Surgery QHC# 63
CATARACT SURGERY Date of Surgery QHC# 63 TABLE OF CONTENTS What is a Cataract?... 3 What Happens During Cataract Surgery?... 4 General Preoperative Instructions... 5 Instilling Eye Drops... 6 Preoperative
More informationPreparing for your Cataract Surgery
Preparing for your Cataract Surgery (without General Anaesthetic) Patient Name: Surgeon: Day Surgery Date of Surgery: Time of Surgery: Check in Time: Check in time is three hours before surgery. Blood
More informationGeneral Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine
PO Box 297 Hedgesville, WV 25427 304 754-8803 KenBarneydds.com General Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine WELCOME TO OUR PRACTICE Welcome to the office of Dr. Kenneth C.
More informationYOUR GUIDE TO TOTAL HIP REPLACEMENT
A Partnership for Better Healthcare A Partnership for Better Healthcare YOUR GUIDE TO TOTAL HIP REPLACEMENT PEI Limited M50 Business Park Ballymount Road Upper Ballymount Dublin 12 Tel: 01-419 6900 Fax:
More informationPersonal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
More information**Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you!
Checking Your Insurance Benefits IMPORTANT Please check your insurance coverage prior to any Nutrition or Diabetes Education appointment. You will be responsible for any services that are not covered.
More informationPATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER
More informationEMPLOYEE GUIDE. To Pre-Tax Savings. Dependent Care Reimbursement Account. Expense Worksheet
EMPLOYEE GUIDE To Pre-Tax Savings Flexible Benefit Flexible Plan Benefit Plan Dependent Care Reimbursement Account Medical Reimbursement Medical Reimbursement Account Account Expense Worksheet Flexible
More informationAdvanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )
More informationNEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
More informationLast Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
More informationGuardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.
More informationTotal knee replacement
Patient Information to be retained by patient What is a total knee replacement? In a total knee replacement the cartilage surfaces of the thigh bone (femur) and leg bone (tibia) are replaced. The cartilage
More informationWelcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
More informationIVC Filter Insertion PROCEDURAL CONSENT FORM. A. Interpreter / cultural needs. B. Procedure. C. Risks of the procedure
DO NOT WRITE IN THIS BINDING MARGIN V4.00-03/2011 SW9264 Facility: A. Interpreter / cultural needs An Interpreter Service is required? Yes No If Yes, is a qualified Interpreter present? Yes No A Cultural
More informationMedicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
More informationSt. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
More informationWarfarin. (Coumadin, Jantoven ) Taking your medication safely
Warfarin (Coumadin, Jantoven ) Taking your medication safely Welcome This booklet is designed to provide you with important information about warfarin to help you take this medication safely and effectively.
More informationMVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
More informationElectroconvulsive Therapy ECT and Your Mental Health
Electroconvulsive Therapy ECT and Your Mental Health Mental Health and Addictions Program St. Joseph s Healthcare Hamilton Charlton Campus 50 Charlton Avenue East Hamilton, Ontario 905-522-1155 ext. 33684
More informationTotal knee replacement: The enhanced recovery programme
INFORMATION FOR PATIENTS Total knee replacement: The enhanced recovery programme Aim This leaflet aims to explain the enhanced recovery programme after total knee replacement surgery, and outline what
More information11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
More informationPATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
More informationEye Surgery PROCEDURAL CONSENT FORM
The State of Queensland (Queensland Health), 2011 Permission to reproduce should be sought from ip_officer@health.qld.gov.au DO NOT WRITE IN THIS BINDING MARGIN v5.00-06/2011 SW9441 Facility: A. Interpreter
More informationPatient Information. Date: Home Phone: Work Phone: Cell: Address: City: State: Zip: Whom may we thank for referring you:
DANIEL LEE, D.D.S. Prev entive Res torative Cosmetic Dentistry Patient Information Date: Home Phone: Work Phone: Cell: Name: Social Security Number: - - Email: Address: City: State: Zip: Sex: M F Birthdate:
More informationHaving a general anaesthetic for your day or short stay surgery
Having a general anaesthetic for your day or short stay surgery This leaflet is for patients having an operation or procedure under a general anaesthetic. It explains what it is, what to expect while in
More informationSLEEP QUESTIONNAIRE THE EPWORTH SLEEPINESS SCALE
SLEEP QUESTIONNAIRE Patient Name: Height: Weight: Date : My Main Sleep Complaint(s) : Trouble sleeping at night.. yes no Falling asleep.. yes no Staying asleep.. yes no Snoring. yes no Stop breathing yes
More informationPatient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #
Patient Information Patient Name Date of Birth If Patient is child, Parent s Name Street Address Male or Female City State Zip Cell# Home# Work# Name of Employer Email Address SS# of Patient Driver s License
More informationFORSTER EYE SURGERY Dr. Geoffrey Whitehouse MBBS(Syd) FRANZCO
GETTING ORGANISED FOR SURGERY 1. BOOKING INTO THE HOSPITAL Once a date has been set for your surgery, you will need to be booked into the hospital. You will have been supplied with an admission form including
More informationRIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
More informationPatient Information Form Pain Management Center at Phoebe
Patient Information Form Pain Management Center at Phoebe Please complete the following form, so that we may facilitate your visit Occupation: or (circle) Retired, Disabled Homemaker, Full time student
More informationPatient Information and Daily Programme for Patients Having Whipple s Surgery (Pancreatico duodenectomy)
Patient Information and Daily Programme for Patients Having Whipple s Surgery (Pancreatico duodenectomy) Date of admission Date of surgery Expected Length of Stay in hospital We will aim to discharge you
More informationTotal Knee Arthroplasty (Knee Replacement) PROCEDURAL CONSENT FORM. A. Interpreter / cultural needs. B. Condition and treatment
The State of Queensland (Queensland Health), 2011 Permission to reproduce should be sought from ip_officer@health.qld.gov.au DO NOT WRITE IN THIS BINDING MARGIN v4.00-04/2011 SW9337 Total Knee Arthroplasty
More informationTrinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with
More informationHow To Write A Medical History Questionnaire For An Aransas Plastic Surgery
Arkansas Plastic Surgery O David H. Bauer, M.D. O Gary E. Talbert, M.D. Appointment Date Patient Information INFORMATION FOR CASE HISTORY FILE Patient s Name: SS# First Middle Last Date of Birth: Patient
More informationOUTPATIENT REHABILITATION CENTER
OUTPATIENT REHABILITATION CENTER 2131 K STREET NW, SUITE 620 WASHINGTON, DC 20037 OFFICE #: 202-715-5655 FAX #: 202-715-5664 Welcome to the George Washington University Hospital Outpatient Rehabilitation
More informationDouglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics Patient s Name Birthdate Who referred you to this office? Social Security # Address City ST ZIP Home Phone Work Phone Ext Cell Phone
More information460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca
Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M
More informationPeriurethral bulking agent for stress urinary incontinence (macroplastique)
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label Who is this leaflet for? This leaflet provides information about having an injection
More informationNew Patient Questionnaire
New Patient Questionnaire Name: Date: Age: Date of Birth: Right or Left Handed: Height: Weight Primary Care Doctor: Address and Phone number: Occupation (If working): Current work status (full duty, light
More information17. Undiagnosed lumps and bumps and unexplained areas of pain. 2. Varicose veins (do not treat anything below the vein site).
15. Acute rheumatism. 16. Asthma. 17. Undiagnosed lumps and bumps and unexplained areas of pain. 18. Whiplash. 19. Slipped Disc. LOCAL CONTRA-INDICATIONS 1. Skin diseases (non contagious). 2. Varicose
More informationFunction First Physical Therapy, P.C. Patient Intake Form
Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married
More informationPATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
More informationPATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
More information***************PATIENT INFORMATION****************
SEP BADY, MD ***************PATIENT INFORMATION**************** TODAYS DATE: / / WHICH DOCTOR ARE YOU SEEING? BADY KURUVILLA LIU OTTEN TRAINOR YEE PATIENT LAST NAME: FIRST: MIDDLE INITIAL: ADDRESS: CITY/STATE:
More informationPlease fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
More informationYour admission for day surgery
Royal Berkshire NHS Foundation Trust London Road Reading Berkshire RG1 5AN 0118 322 5111 (switchboard) West Berkshire Community Hospital London Road, Benham Hill Thatcham Berkshire RG18 3AS 01635 273300
More informationMEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
More informationWilliam O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737 Workers Compensation Form First Name MI Last Name Sex Date of Birth Social Security
More informationLocal anaesthesia for your eye operation
Local anaesthesia for your eye operation A short guide for patients and families. This is for anyone expecting to have an eye operation with a local anaesthetic. It does not give detailed information about
More informationPatient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
More informationEmployee Guide to Pre-Tax Savings
Employee Guide to Pre-Tax Savings Flexible Benefit Plan Information What is a Flexible Benefit Plan? What expenses qualify for reimbursement? Can I use funds I have set aside for dependent care to pay
More informationA patient s guide to the. management of diabetes at the time of surgery
A patient s guide to the management of diabetes at the time of surgery Diabetes is a common condition, affecting at least 4 to 5% of people in the UK. At least 10% of patients undergoing surgery have diabetes.
More informationPENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account #
PENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account # PATIENT INFORMATION QUESTIONNAIRE Patient Name Resp. Party/Spouse Address Address City, State, Zip
More informationTotal hip replacement
Patient Information to be retained by patient What is a total hip replacement? In a total hip replacement both the ball (femoral or thigh bone) side of the hip joint and the socket (acetabular or pelvic
More informationPatient Information Leaflet: Part 1 select-d
Patient Information Leaflet: Part 1 select-d Anticoagulation Therapy in SELECTeD Cancer Patients at Risk of Recurrence of Venous Thromboembolism Introduction This
More informationHolistic Chiropractic and Craniosacral Therapy. Rosewood Family Healing Center - Dr. Maura Moynihan
Holistic Chiropractic and Craniosacral Therapy Rosewood Family Healing Center - Dr. Maura Moynihan Print Name Date Email Date of Birth Age Phone Number Marital Status- M D S W Occupation # of hours/day
More informationTransrectal Ultrasound (Trus) Guided Prostate Biopsies Urology Patient Information Leaflet
Transrectal Ultrasound (Trus) Guided Prostate Biopsies Urology Patient Information Leaflet Page 1 What is the purpose of my appointment? Your doctor has informed us that you have an elevated Prostate Specific
More information