Patient Information TODAY'S DATE:
Patient Information
NAME: AGE: DATE OF BIRTH:
ADDRESS: SEX: MARITAL STATUS:
CITY: STATE ZIP email:
DID YOU SEE OUR WEBSITE ___Yes ____No SOCIAL SEC #:
ARE WE IN YOUR PLAN DIRECTORY? ____Yes ____No DRIVERS LICENSE # State
PERMANENT ADDRESS:
EMPLOYER: CITY/ST/ZIP:
ADDRESS: HOME PHONE #:
CITY/ST/ZIP: WORK PHONE #:
PHONE #: MOBILE PHONE#:
Responsible Party Information
NAME: RELATION TO PATIENT:
ADDRESS: EMPLOYER:
CITY/ST/ZIP: ADDRESS:
HOME PHONE: CITY/ST/ZIP:
SOCIAL SECURITY #: WORK PHONE:
Primary Insurance (Please give your insurance card(s) to the receptionist)
INSURANCE CO.: POLICYHOLDER'S NAME:
ADDRESS: POLICYHOLDER SSN:
CITY/ST/ZIP: POLICYHOLDER D.O.B:
PHONE # POLICY #:
Effective dates: through GROUP #:
PLAN NAME COPAY $ RELATION TO PATIENT:
POLICYHOLDER'S EMPLOYER:
Additional / Secondary Insurance
INSURANCE CO.: POLICYHOLDER'S NAME:
ADDRESS: POLICYHOLDER SSN:
CITY/ST/ZIP: POLICYHOLDER D.O.B:
PHONE # POLICY #:
Effective dates: through GROUP #:
PLAN NAME COPAY $ RELATION TO PATIENT:
POLICYHOLDER'S EMPLOYER:
Miscellaneous
In case of emergency, notify Relation to patient
Home phone Work phone
Signature
The undersigned verifies that the above information is true and correct.
Signature: Date:
(If patient is a minor - signature of parent/guardian)
Patient Communication Authorization
Date:
Patient's Name:
Patient's Date of Birth:
We must call on occasion to discuss confidential protected health information. Below is a list
of potential ways for us to communicate this information. Please indicate how you would like
us to get this information to you:
It's okay to call my home phone number. Okay to leave a message? yes no
It's okay to call my mobile phone number. Okay to leave a message? yes no
It's okay to call my work phone number Okay to leave a message? yes no
Call only this number. ________________________ Okay to leave a message? yes no
Do not speak to family members
I give permission to the individual(s) listed below to receive protected health information:
This authorization can be revoked or modified by notifying us IN WRITING at any time.
Patient’s Signature Date
PATIENT QUESTIONNAIRE
Patient's Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Birth Date _ _ _ _ Sex _ _ S. M. LTP. W. D.
Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _:--_ _ _ _ _ _ _ _ _ _ _ _ _ Tel. No. _ _ _ _ __
DHMO Copay $ _ __ Primary care
Insurance Co. _ _ _ _ _ _ _ _ _ _ _ DPPO Copay $ _ __ Referred
Physician By _ _ _ _ _ Occupation _ _ _ _ __
Mail Claim To _ _ _ _ _ _-=____________________ Policy No. _ _ _ _ _ _ _ _ __
Instructions: Put Gd In Those Boxes Applicable To You And In The "Yes" Or "No" Space. If Lines Are Provided Write In Your Answer.
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Age (if Living)
Health (G) Good (B) Bad
Cancer
Diabetes
Heart Trouble
High Blood Pressure
Stroke
Epilepsy
Nervous"
Asthma, Hives. Hay Fever
Blood Disease
Age (At Death)
Cause Of Death
nave~.pu~verhao·. •.•.••• / ..... .i 1NQ··.·IYes
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ulpnmeria Epilepsy Recurrent niIIIIIIII/.·...IIIIIIII ,..N~O .
. . .......... . ,Y! •
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Tonsils DOvary 0 Ovaries Had Hernia Repaired
Appendix n"",u""u,u" Had Any Other ~"'Q'U'" ,,~
Gall Bladder Ever Have A Tram"" inn Been i ,Ii. For Any Illness
Uterus DBlood 0 Plasma Explain
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Gall Bladder
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Mammogl
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o Eye Disease 0 Eye InjlJl}' 0 Impaired Sight Kidney o Disease o Stones
o Ear Disease 0 Ear Injury 0 Impaired Hearing
Any Trouble With 0 Nose ~ Sinuses 0 Mouth 0 Throat Blood In Urine
Fainting Spells o Protein gSugar _OPus j:J0therlnUrine
Convulsions Difficulty In Urination
,Par~ Narrowed Urinary Stream
Dizziness Abnormal Thirst
n"""""''''',,, o Frequen~ OS~re Prostate Trouble
Enlarged Glands o Stomach Trouble o Ulcer
Thyroid: OOV"'a""V" 0 "uo,a"uvo OEnla~ I"di;"o.>\ic"
Enlarged Goiter OGas Uijelcnmg
Skin Disease "'f'f'0"ui"";,,,
Cough: o Frequent 0 Chronic o Liver Disease o Gall Bladder Disease
o Chest Pain 0 Angina Pectoris o Colitis OOther Bowel Disease
Spitting Up Blood o ,,,,,,u, ,ul"", o Rectal.Blee~
Night Sweats BlackIarry Sto~
Shortness 01 Breath o Exertion o At Night OVOn""l-'dIUI o Diarrhea
o 'a'f'"adu" o Fluttering Heart o Parasites 0 Worms
Swelling 01 o Hands o Feet o Ankles OAny Change In Appetite o Eating Habits
Varicose Veins OAny Change In Bowel Action o Stools
Extreme OTirednes~ 0 ,,,a,,""""'. Explain
.··"'·'·Hact·;,·; • ·········,· ......•••.•.••••.•••...•.•..•••.•.,. "......•......••...••....••.•. ,.•. . .•.••••.•. . ,.•.,••.. ."'Ha\f~':;~_ ..;..................... : •.. .. ,.,........ ·•. ·.?i···:;·i·.·.::····· . C·. Nt): 1"(.99..
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Smal~ ,a,,"u ,auu, (W~ 'Years) Polio Shots (Within Last 2 Years)
Tetanus Shot (Not Antitoxin) An I i ram When
Hepatitis i
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Ex~ .rlan,,~tah, Laxatil/EJs
How? Vitamins
Awaken Rested
Sleep Well T~izers
Average 8 Hours Sleep (Per Night) Sleeping Pi~
Have Regular Bowel IV'UV"" '''' "" Aspirins
Sex Entirely i Co~e
Like Your Work ( Hours Per Day) 0 I~ O~ors Alcoholic 80vo, a",,,,,,
Watch Television ( Hours Per Day) Tobacco: vlg~enes ( Pks Per Day),
Read ( Hours Per Day) OCigars OPipe OChewing Tobacco
Have A Vacation ( Weeks Per Year) o Snuff
Have You Ever Been Treated For I-IIWIlUlibll o Other Drugs
Have You Ever Been Treated For Drug Abuse Appetite Dpn",cc~ntc
Recreation: Do You Participate In Sports Or Have Thyroid ", 0 No 0 Yes, In Past ONone Now Now On Gr. Daily
Hobbies Which Give You Relaxation At Have You Ever Taken:
Least 3 Hours A Week? o Insulin OTablets For Diabetes []Hormone Shots OTablets ONo
. M ..ntr"",1 .1- let"", ; ..
'.
.. ] No J Yes ........ .. ..........:... .. .......... .. .
Nr. .V"
Age At Onset Are You Regular: 0 Heavy 0 Medium OUght
_Usu~ation Of.F'eriod Da~ Do You Have lension 0 i Before Period
Cycle (Start To Start) Days Do You Have 'jlJramps 0 Pain With Period
Date 01 Last Period Do You Have Hot Flashes
,o",,,a,,,,,o,,,, , , No Yes No Yes
Children Born Alive (How Many ) Still Born (How Many )
Cesarean Sections (HowM~ ) Miscarriages (How Many )
Prematures ~Mall\l. ) Any Con 'flIiLdu""
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Dbf"""'''''''' Jumpy
Anxious Jittery
Irritable Is i I Difficult?
INFORMED CONSENT FOR PROCTOLOGY PROCEDURES
The doctor requests that you to sign this consent form before he meets with you today. This
form will explain the risks that patients’ assume when they seek the services of a proctologist.
You will have an opportunity to ask your doctor questions regarding any surgery or procedure,
and you will have a right to decline any procedures before it is to begin.
Your doctor may ask you to consider having a diagnostic procedure called a colonoscopy or
endoscopy. These are procedures in which the doctor inserts a special scope into the gastro-
intestinal tract. This scope allows the doctor to see inside the stomach or colon, and to perform
simple surgical procedures inside the stomach or colon. The removal of polyps and a biopsy of
the stomach or colon are the most common surgical procedures done by endoscopy. These
procedures are done to aid in the diagnosis of stomach and or colorectal disease, and to prevent
the spread of cancer. Your doctor can make no guarantee that the colonoscopy or endoscopy
procedure will be successful in making either a diagnosis or a cure. Significant complications
from endoscopy are very uncommon (less than 0.3 %), but they do sometimes occur.
Your doctor may ask you to consider having surgical procedures on the anus or rectum.
Depending upon your circumstances, it is possible that your doctor may recommend several
surgical operations or treatments spanning several weeks. Your doctor can make no guarantee that
your problem will be either corrected or cured by these procedures. Complications from anorectal
surgery can occur. If they do occur, most are corrected easily.
Risks and alternatives to having rectal surgery, colonoscopy and endoscopy are as follows:
• Bleeding – It is possible for some bleeding of the stomach, colon & rectum to occur with this
procedure. If bleeding should occur, it usually stops by itself. Only in rare cases will a blood
transfusion ever be necessary.
• Allergy - Taking the pharmaceutical, nutritional, and or botanical nutraceuticals prescribed by
your physician has been shown to minimize the negative effects of medications and anesthesia.
However, it is still possible to have a life threatening reaction to one or more of the medications,
including to the anesthesia that you will receive during the course of your treatment.
• Perforation – A very rare, but significant complication is a perforation. This is when a hole is
made in the lining of the wall of the colon, intestines, esophagus or stomach.
• Unforeseen complications - In addition, it is possible to have unforeseen complications that are
not listed here. Some of the complications from this procedure may require major surgery; some
of the complications may require blood replacement therapy; some of the complications can cause
poor healing wounds; permanent disability; permanent deformity; and scarring. Very, very rarely,
some complications can be fatal.
• Alternative to colonoscopy and endoscopy procedures - There may be alternatives to this
procedure available to you, such as the use of other diagnostic tests, virtual colonoscopy, the
barium enema, and the barium swallow evaluation. However, these alternative methods carry
their own risk of complications and a varying degree of success. Therefore in those patients in
whom colonoscopy or endoscopy is indicated, that procedure provides the patient with the best
chance of successful diagnosis and treatment and the lowest risk of complications.
• Urinary Retention – If this occurs it is usually associated with anal muscle spasm after surgery,
and or an enlarged prostate. This problem improves quickly during recovery. However, in
extreme cases of urinary retention, catheterization by emergency room personnel may be
necessary.
1|Page
• Rectal Stenosis - A rare complication that can occur from rectal surgery is a tightening of the anal
canal with the formation of excess scar tissue. This condition if it should occur, is usually
corrected easily using a simple procedure to cut away and remove scar tissue. However, it’s
possible for this to become a chronic reoccurring condition after treatment.
• Infection after rectal surgery - Proper adherence to a prescribed diet, adequate hydration, exercise,
rest, and a proper mental attitude helps your immune system function at its highest level.
However, it is still possible for the postoperative site not to heal completely. Sometimes, the body
does not have the ability to resist infection in the surgical wound site. This infection can form a
chronic sore, localized abscess draining pus, crack or fissure; and in some instances, cause the
whole body to become very sick. Rarely, this condition can be life threatening.
• Fecal incontinence – This is the failure of voluntary control of the anal sphincter muscles, with
involuntary passage of stool or gas. This condition is rare after rectal surgery, but it can happen.
• Alternatives to rectal surgery may be available to you, such as repeated local injections to the
problem area; or the use of rectal suppositories and other medicines. However, these alternative
methods carry their own risk of complications and a varying degree of success. Therefore in those
patients in whom anorectal surgery is indicated, the recommended procedure will always be one
that provides the patient with the best chance of successful treatment and the lowest risk of
complications. Additionally:
You have the right to ask questions and to refuse any treatment. However, once a procedure
has begun, you are authorizing your physician to do whatever he deems to be advisable in your
interest. Without your prior knowledge, if any unforeseen condition arises during a procedure,
your physician may call for additional diagnostic tests, procedures, operations or medication
(including anesthesia and a blood transfusion), for which there is a specific indication or need.
Additionally, in the event that medical personnel should inadvertently get stuck with a sharp
instrument and or contaminated with your blood, your blood may be tested for infectious diseases,
including HIV.
Your doctor may require a surgical assistant to help with your operation. Other physicians,
medical students, or medical equipment personnel may also be present. If so, then you may not be
notified in advance of your doctor’s decision to have such persons present during the operation.
Your doctor may be one who travels frequently to and from places far away, and may be
unavailable to you in the event of a complication or an emergency situation. Should this occur,
you may need to follow up with care for your surgical procedure with another physician who is on
call, or you may have to go to the nearest hospital emergency room for care and treatment by
physicians unknown. Or, you can arrange in advance to have another doctor perform proctology
procedures, one who does not travel.
I certify that I have read or had read to me the contents of this form. I understand that
there are risks and alternatives to most surgical and diagnostic procedures. I understand
that I am encouraged to ask more questions at the time of scheduling, and before the start of
any surgery or procedure; and that if I feel uncomfortable for any reason, I have the right
to refuse treatment.
SIGNED: _____________________________________
WITNESS: ____________________________________ DATE: ________________
2|Page
Clinic Policies
Acknowledgement & Consent
Patient name: ______________________________________________ Date of birth: ______________
I acknowledge that all of the information supplied on the patient registration form is true and
correct and that it has been furnished to this office with full knowledge that the patient is liable for
all said services rendered and that he/she is contractually bound to pay for said services, including
all costs of collection and a reasonable attorney's fee should collection become necessary. Patient
hereby waives his/her confidentiality rights should collection action become necessary. I hereby
authorize and request that payments under my insurance plans be made directly to the medical
clinic for any services furnished to me.
I hereby consent to the administration and performance of all diagnostic procedures and/or
treatments which in the judgment of my doctor may be considered necessary and advisable. I am
entitled to a full explanation prior to any testing, procedure, or referral and that I have the option to
decline such treatment or seek further information.
I understand that all inactive medical records are destroyed after six years; and that if I want them I
need to claim them before six years. I also authorize the release of any information required to
process insurance claims including any information relating to drug or alcohol abuse, and AIDS/HIV.
Financial Arrangements
For your convenience, our clinic participates with most insurance plans. Our list of plans may change
periodically. You are responsible for making sure that we are currently participating with your
carrier. You are responsible to notify us which diagnostic testing laboratory your insurance is
contracted with, otherwise you may be liable for non-contracted laboratory services.
We offer the following methods of payment: Cash, Personal Check, Visa, and MasterCard. If you do
not have insurance, we require full payment at the time of service. If you have any questions
concerning financial arrangements or need special arrangements, please ask for assistance prior to
your appointment.
Forms are completed free of charge on or before the day of surgery or during your 30-day post-
operative check up. At any other time, I agree to pay for any letter; note; forms required for a
return to work, disability, insurance, DMV, or for legal purposes; that I request to be completed and
signed at $50/page and $25 each additional page. I agree to pay a $6.00 rebilling fee for each month
that I carry a balance beyond 60 days. I agree to pay $60 for a missed appointment or $600 for a
missed surgery if cancelled with less than 16 hours notice.
Acknowledgment of Receipt of Privacy Notice
I have been presented with a copy of the clinics ”Notice of Privacy Policies”, detailing how my
information may be used and disclosed as permitted under federal and state law. I understand the
contents of the Notice, and I place no additional restriction(s) concerning my personal medical
information: __________________________________________________________________________.
This authorization may be revoked in writing by me at any time.
Signed: ____________________________________________________ Date:_____________________
(If patient is a minor - signature of parent/guardian)
We will use your health information for regular Funeral directors: We may disclose health
health operations. information to funeral directors consistent with
applicable law to carry out their duties.
For example: Members of the medical staff, the
risk or quality improvement manager, or members Organ procurement organizations: Consistent with
of the quality improvement team may use applicable law, we may disclose health information
information in your health record to assess the care to organ procurement organizations or other
and outcomes in your case and others like it. This entities engaged in the procurement, banking, or
information will then be used in an effort to transplantation of organs for the purpose of tissue
continually improve the quality of care. donation and transplant.
Business associates: There are some services Marketing: We may contact you to provide
provided in our organization through contacts with appointment reminders or information about
business associates. Examples include physician treatment alternatives or other health-related
services in the emergency department and benefits and services that may be of interest to
radiology, certain laboratory tests, billing services, you.
and a copy service we may use when making
copies of your health record. When these services Food and Drug Administration (FDA): We may NOTICE OF
are contracted, we may disclose your health disclose to the FDA health information relative to
information to our business associate so that they adverse events with respect to food, supplements, PRIVACY POLICIES
can perform the job we've asked them to do and bill product and product defects, or post marketing
you or your third-party payer for services rendered. surveillance information to enable product recalls,
To protect your health information; we require the repairs, or replacement.
business associate to safeguard your information.
Workers compensation: We may disclose health
Directory: Unless you notify us that you object, we information to the extent authorized by and to the
will use your name, location in the facility, general extent necessary to comply with laws relating to
condition for directory purposes. This information workers compensation or other similar programs
may be provided to people who ask for you by established by law.
name.
Public health: As required by law, we may disclose
Notification: We may use or disclose information to your health information to public health or legal
notify or assist in notifying a family member, authorities charged with preventing or controlling
personal representative, or another person disease, injury, or disability.
responsible for your care, your location, and
general condition. Law enforcement We may disclose health
information for law enforcement purposes as
Communication with family: Health professionals, required by law or in response to a valid
using their best judgment, may disclose to a family subpoena.
member, other relative, close personal friend or any
other person you. identify, health information Federal law makes provision for your health
relevant to that persoh's involvement in your care or information to be released to an appropriate health
payment related to your care. oversight agency, public health authority or
attorney, provided that a work force member or
Research: We may disclose information to business associate believes in good faith that we
researchers when their research has been have engaged in unlawful conduct or have
approved by an institutional review board that has otherwise violated professional or clinical
reviewed the research proposal and established standards and are potentially endangering one or Revision Number1.0.
protocols to ensure the privacy of your health more patients, workers or the public. January 2009
information.
THIS NOTICE DESCRIBES HOW INFORMATION Your Health Information Rights according to the procedures included in the
ABOUT YOU MAY BE USED AND DISCLOSED AND authorization.
HOW YOU CAN GET ACCESS TO THIS INFORMATION. Although your health record is the physical
PLEASE REVIEW IT CAREFULLY.
property of our clinic, the information belongs to For More Information or to Report a Problem
you. You have the right to:
Introduction If have questions, please contact the practice's Privacy
Obtain a paper copy of this notice of information Officer/Office Manager for additional information.
At our clinic, we are committed to treating and using practices upon request,
your protected health information responsibly. This Inspect and copy your health record as provided If you believe your privacy rights have been violated,
Notice of Health Information Practices describes for in 45 CFR 164.524, you can file a complaint with the practice's Privacy
the personal information we collect, and how and Amend your health record as provided in 45 CFR Officer or with the Office for Civil Rights, U.S.
when we use or disclose that information. It also 164.528, Department of Health and Human Services. There will
describes your rights as they relate to your Obtain an accounting of disclosures of your health be no retaliation for filing a complaint with either the
protected health information. This Notice is information as provided in 45 CFR 164.528, Privacy Officer or the Office for Civil Rights. The
effective April 2003, and applies to a" protected Request communications of your health address for the OCR is listed below:
health information as defined by federal regulations. information by alternative means or at alternative
locations, Office for Civil Rights
Understanding Your Health Recordllnformation U.S. Department of Health and Human Services
Request a restriction on certain uses and
disclosures of your information as provided by 200 Independence Avenue, S.W.
Each time you are seen at our clinic, a record of 45 CFR 164.522, and Room 509F, HHH Building
your visit is made. Typically, this record contains Revoke your authorization to use or disclose Washington, D.C. 20201
your symptoms, examination and test results, health information except to the extent that
diagnoses, treatment, and a plan for future care or action has already been taken. Examples of Disclosures for Treatment, Payment
treatment. This information, often referred to as and Health Operations
your health or medical record, serves as a: Our Responsibilities
We are required to: We will use your health information for treatment.
Basis for planning your care and treatment,
Means of communication among the many health Maintain the privacy of your health information, For example: Information obtained by a nurse,
professionals who contribute to your care, Provide you with this notice as to our legal duties physician, or other member of your health care team will
Legal document describing the care you received, and privacy practices with respect to information be recorded in your record and used to determine the
Means by which you or a third-party payer can we collect and maintain about you, course of treatment that should work best for you. Your
verify that services billed were actually provided, Abide by the terms of this notice, physician will document in your record his or her
A tool in educating health professionals, Notify you if we are unable to agree to a requested expectations of the members of your health care team.
A source of data for medical research, restriction, and Members of your health care team will then record the
A source of information for public health officials Accommodate reasonable requests you may have actions they took and their observations. In that way, the
charged with improving the health of this state and to communicate health information by alternative physician will know how you are responding to
the nation, means or at alternative locations. treatment.
A source of data for our planning and marketing,
A tool with which we can assess and continually We reserve the right to change our practices and We wi" also provide your physician or a subsequent
work to improve the care we render and the to make the new provisions effective for a" health care provider with copies of various reports that
outcomes we achieve, protected health information we maintain. Should should assist him or her in treating you once you're
our information practices change, we will mail a discharged from this hospital.
Understanding what is in your record and how your revised notice to the address you've supplied us,
health information is used helps you to: ensure its or if you agree, we will email the revised notice to We will use your health information for payment.
accuracy, better understand who, what, when, you.
where, and why others may access your health For example: A bill may be sent to you or a third-party
information, and make more informed decisions We will not use or disclose your health information payer. The information on or accompanying the bill may
when authorizing disclosure to others without your authorization, except as described in include information that identifies you, as we" as your
this notice. We will also discontinue to use or diagnosis, procedures, and supplies used.
disclose your health information after we have
received a written revocation of the authorization