Click on this link New Patient Florida Neurovascular by mikesanye

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									                  Please fill out this New Patient Information Packet and return the completed document by
                  mail, email, or fax. All information must be received in office at least 48 hours prior to your
                              appointment or your appointment will be automatically rescheduled.


                                       FLORIDA NEUROVASCULAR INSTITUTE
                                                       Welcome to Florida Neurovascular Institute!

                                           Please fill out this New Patient Information Packet and return the
                                           completed document by mail, email, or fax. All information must be
                                           received in office at least 48 hours prior to your appointment or your
                                           appointment will be automatically rescheduled.

                                           You must give 48 hours notice prior to cancellation of your
5 Tampa General Circle
                                           appointment or you will be charged a $50.00 fee for a missed
Harbourside Medical
Tower, Suite 200                           appointment.
Tampa, FL 33606-3500
                                                      If your insurance is an HMO or you are a county patient,
Phone: (813) 250-9101                                  please make sure you have a current referral.
Fax: (813) 844-4952
                                                      Bring your CT-scan films or MRI films of your brain or
prev entastroke@floridastroke.com                      spine to your visit. If you do not bring your film with you,
                                                       we will have to reschedule your appointment.

                                                      Recent lab results (blood work)

                                                      Results from recent Echocardiograms and Carotid
Erfan A. Albakri, M.D.                                 Doppler scans
  Medical Director
  Vascular Neuro logy/Stroke                          Recent records from your referred doctor, your primary
                                                       care doctor, or any specialists you are seeing

Administration:                                       If you were recently in any hospital, we will need your
                                                       hospital records.
Betty Stewart
 Chief Operating Officer                              Please list all physicians that you see and their telephone
                                                       number and address.
Roger Shaw
  Neurodiagnostic Technologist
                                                      Please bring a list of your current medication with dosages.
Andrea Zevchack
  Chief Financial Officer                             If you were in Tampa General Hospital we will obtain your
  Co mp lian ce
                                                       medical records, except for the film. You will need to
Li s a S teff y                                        obtain the film from Tampa General Hospital.
  Ultr aso un d Tech
                                           If you are unable to provide us with the necessary information, we will
Is aia h An to nek , R .N .                need to reschedule your appointment for another day.
  St r ok e Research Coo r din ato r

                                           Thank you for your help. We hope this process will enable your visit to
                                           go more smoothly. We are here to help you. Let us know if you have
                                           any questions or if there is anything we can do to make your
                                           appointment less stressful.
Stroke Clinic
Vascular Prevention Clinic
Headache Clinic                            Your appointment is scheduled for:
Memory Disorder Clinic                     Date ___________________________
Neuromuscular Clinic
                                           Time ___________________________
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.

                                New Patient Information

Patient Name ____________________________________________________________
                  First                           M.I.                     Last

Home Address ___________________________________________________________
City _________________________ State ___________________ Zip Code __________

Primary Phone (           )        -          Secondary Phone (              )         - ______

Social Security ________-_______-________ Date of Birth ______/________/________
                                                                      MM          DD     YYYY

Emergency Contact Number (                )        -       .Name____________________
Relationship __________________________________________
E- mail _______________________________________________
Please check one: Right Handed ________
                  Left Handed          ________
Sex:              Male _______
                  Female _______
Race ________________________________________________
Marital Status ____________________________ Number of Children _______________
Occupation ______________________________________________________________
Employer Name __________________________________________________________
Employer Address ________________________________________________________
City _________________________ State __________________ Zip Code ___________

Phone (       )               - __________
Referring Physician Name __________________________________________________
Address ________________________________________________________________

Phone (       )               - _____________ Fax (               )               - __________
Primary Physician’s Name __________________________________________________
Address ________________________________________________________________
City _________________________ State ___________________ Zip Code __________

Phone (       )               -__________________ Fax (           )               - __________
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.


                             Insurance Information

Insurance Company _______________________________________________________
Insurance Primary Policy #_____________________ Group ______________________
Secondary Policy # ___________________________ Group ______________________
Third Policy # _______________________________ Group ______________________

If you have any type of HMO, please make sure you have a referral prior to your
visit.

I authorize release of any information necessary to process my insurance claims and
assign and request payment directly to my physician. (Please list any other physicians
you see along with their phone numbe r and address on the back of this page.)



Patient Signature ______________________________ Date ______/________/_______
                                                               MM       DD       YYYY
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.

            FLORIDA NEUROVASCULAR INSTITUTE
        Harbourside Medical Tower 4 Columbia Dr. Suite 200 Tampa, FL 33606


                                       Erfan A. Albakri, M.D.
                   5 Tampa General Circle | Harbourside Medical Tower, Suite 200
                                      Tampa, FL 33606-3500
                           Phone: (813) 250-9101 | Fax: (813) 844-4952
                            E-mail: preventastroke@floridastroke.com




                                   New Patient Information


Patient Name _____________________________________________________________



My authorization to release confidential information regarding my medical status to:

Florida Neurovascular Institute Erfan Albakri, M.D.

4 Columbia Dr. Suite 200, Tampa, FL33606


                     Initial Evaluation
                     Follow up Notes
                     Hospital Admission History & Physical
                     Hospital Discharge Summary
                     CT Scan of Brain
                     MRI or MRA
                     Carotid Ultrasound
                     Labs


Patient Signature ______________________________ Date ______/________/_______
                                                                MM        DD       YYYY



Patient Social Security Number ___________-_________-__________
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.

                                  Medication Records

Patient Name __________________________________________________________________


Pharmacy ___________________________ Pharmacy Phone (                  )        - _________


Allergies: _____________________________________________________________________


   Name of        Milligrams                                    Prescribing          Reason
                                How Often       Stop Date
  Medication        (MG)                                         Physician          Prescribed
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.



Please list any over the counter medications used. _____________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________




Patient Name _____________________________________ Date ______/________/_________
                                                                     MM       DD         YYYY
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.

                                      Medical History
Please X next to the health conditions that you currently have or have had.


                     Heart                             Nervous System & Muscles


______ Atrial Fibrillation                                  Alzheimer’s/Memory
          CABD (Coronary Artery Bypass            ______      Condition
______      Graft)                                ______ Arthritis
______ Carotid Artery Disease                     ______ Cerebral Aneurysm
______ Coronary Angioplasty                       ______ Cervical/Spinal Disease
______ Coronary Artery Disease                    ______ Cervical Spinal Surgery
          Deep Vein Thrombosis/PE                 ______ Dementia/Memory Disorder
______      (Pulmonary Embolism)                  ______ Depression
______ Heart Attack                               ______ Anxiety
______ Heart Disease                              ______ Epilepsy/Seizures
______ Heart Failure                              ______ Headache
______ Heart Murmur                               ______ Lumbar Spinal Disease
______ Heart Transplant                           ______ Lumbar Spine Surgery
          High Cholesterol/High                   ______ Migraine
______      Triglycerides                         ______ Multiple Sclerosis
______ Hyperthyroidism                            ______ Myasthenia Gravis
______ Hypothyroidism                             ______ Neuropathy
______ Pacemaker                                  ______ Parkinson’s Disease
______ Permanent Pacemaker                        ______ Tremors
______ Subarachnoid Hemorrhage                    ______ Stroke
______ Syphilis                                   ______ Subdural Hematoma
______ TIA (Transient Artery Disease)
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.



                  Kidney                                          Lung

______   Diabetes/High Blood Sugar:              ______ Bronchial Asthma
______     Adult Onset; or,                      ______ COPD
______     Juvenile Onset                        ______ Lung Transplant
______   End Stage Kidney Disease                ______ Pneumonia
______   Kidney Transplant                       ______ Pulmonary Disease
______   Pancreas Transplant                     ______ Tuberculosis
______   Renal Insufficiency
Cancer; please specify ______________________________________________________
______   Hepatitis
______ Hysterectomy
______ Jaundice
______ Liver Transplant
______ Pancreas Transplant
______ Peptic Ulcer
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.

                                       Hospitalization
           Hospital                            Date                           Reason




Procedures (If yes, please give date and location.)

      Have you ever had a Brain CT?                        Date ______/________/_________
                                                                   MM        DD        YYYY
Location ______________________________________________________________________

      Have you ever had a Brain MRI or MRA?                Date ______/________/_________
                                                                   MM        DD        YYYY
Location ______________________________________________________________________

      Have you ever had a Carotid Ultrasound?              Date ______/________/_________
                                                                   MM        DD        YYYY
Location _____________________________________________________________________

      Have you ever had Carotid Surgery?                   Date ______/________/_________
                                                                   MM        DD        YYYY
Location ______________________________________________________________________

      Have you ever had a Transcranial Doppler?            Date ______/________/_________
                                                                   MM        DD        YYYY
Location ______________________________________________________________________

      Have you ever had an Echocardiogram?           Date ______/________/_________
                                                                   MM        DD        YYYY
Location ______________________________________________________________________

      Have you ever had an Ultrasound of the legs?         Date ______/________/_________
                                                                   MM        DD        YYYY
Location _____________________________________________________________________

      Have you ever had lab work or blood tests?           Date ______/________/_________
                                                                   MM        DD        YYYY
Location ______________________________________________________________________
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.

                                            Lifestyle
Diet

Are you on a special diet? Please circle:                   YES            NO

If yes, what type? _______________________________________________________________


Tobacco Use

Do you use tobacco? Please circle:

NEVER                    USED TO SMOKE                  or, YEAR QUIT _______

STILL SMOKE: ______ Packs/Day                 SMOKELESS TOBACCO: _________ Packs/Day


Alcohol Usage

Do you drink alcoholic beverages? Please circle:            YES            NO

If yes, how many drinks in a typical day? _____________ or, Special Occasions? ___________


Fat Intake

How many times a week do you eat food such as fatty meat, cheese, fried foods, or eggs? ______


Other Beverages and Food

Do you consume caffeine? Please circle:                     YES            NO

If yes, please X typical caffeinated beverage(s):           Cola ______ Coffee       ______


                                                            Tea ______ Chocolate ______

Physical Exercise

On an average, how many times do you do exercise per week? _________________________

What type? _______________________            Exercise Duration: ________________________
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.

                                        Family History

            Father                              Mother                            Siblings


  Alive ____ Deceased ____          Alive ____ Deceased ____            Age ______ Age ______
 Age ____                            Age ____                           Age ______ Age ______
    Has he had any of the              Has she had any of the           Have they had any of the
     following illnesses?               following illnesses?               following illnesses?

Alzheimer’s/Memory                 Alzheimer’s/Memory                 Alzheimer’s/Memory
 Disorder                   ____     Disorder                  ____    Disorder               ____
Alcohol Abuse               ____   Alcohol Abuse               ____ Alcohol Abuse             ____
Diabetes/High Blood                Diabetes/High Blood                Diabetes/High Blood
 Sugar                      ____     Sugar                     ____     Sugar                 ____
Cancer;                            Cancer;                            Cancer;
 please specify ___________         please specify ___________         Please specify __________
DVT (Deep Vein                     DVT (Deep Vein                     DVT (Deep Vein
 Thrombosis)                ____     Thrombosis)               ____   Thrombosis)             ____
Headaches                   ____   Headaches                   ____ Headaches                 ____
Heart Disease               ____   Heart Disease               ____ Heart Disease             ____
Hyperlipidemia              ____   Hyperlipidemia              ____ Hyperlipidemia            ____
Hypertension                ____   Hypertension                ____ Hypertension              ____
Multiple Sclerosis          ____   Multiple Sclerosis          ____ Multiple Sclerosis        ____
Parkinson’s Disease/               Parkinson’s Disease/               Parkinson’s Disease/
 Tremors                    ____    Tremors                    ____    Tremors                ____
PE (Pulmonary                      PE (Pulmonary                      PE (Pulmonary
                            ____                               ____
 Embolism)                          Embolism)                          Embolism)              ____
                            ____                               ____
Seizures                           Seizures                           Seizures                ____
                            ____                               ____
Stroke                             Stroke                             Stroke                  ____
                            ____                               ____
Thyroid                            Thyroid                            Thyroid                 ____
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.


1. Please list the family members, next of kin, or a significant other to whom we may disclose
    your medical condition in the event of an emergency.

   Name____________________________________ Phone (                   )         - __________


   Name____________________________________ Phone (                   )         - __________


2. Please print the address of where you would like your billing statement and/or correspondence
    from our office to be sent if other than your home.

   Address ___________________________________________________________________

   City ________________________ State ___________________ Zip Code ______________


3. Do you want all correspondence from our office to be sent in a sealed envelope marked
   CONFIDENTIAL? Please circle:         YES           NO


4. Please print the telephone number to where you want to receive calls about your appointment,
    lab and x-ray results, or other health care information if other then your home phone number.

   (        )      - ___________


5. Can confidential messages or appointment reminders be left on your telephone answering
   machine or voicemail? Please circle:  YES           NO


   Patient Name: _______________________________________________________________

   Patient/Guardian Signature: ____________________________________________________

   Date ______/________/_________
            MM       DD      YYYY
Please fill out this New Patient Information Packet and return the completed document by
mail, email, or fax. All information must be received in office at least 48 hours prior to your
            appointment or your appointment will be automatically rescheduled.

                            Patient Acknowledgement Form
   Our notice of Privacy Practices provides information about how we may use and disclose
   protected health information about you. Please read the notice before signing your consent.
   The terms of our notice may change. If we change our notice, you may obtain a revised copy
   by contacting our office.

   You have the right to request that we restrict how protected health information about you is
   used or disclosed for treatment, payment or health care operations. We are not required to
   agree to this restriction, but if we do we shall honor that agreement.

   By signing this form you consent to our use and disclosure of protected health information
   about you for treatment, payment, and health care operations. You have the right to revoke
   this consent, in writing and signed you. However, such a revocation shall not affect any
   disclosures we have already made in reliance of your prior consent. The practice provides
   this form to comply with the Health Insurance Portability and Accountability Act of 1996
   (HIPAA).

   The patient understands that:

      Protected health information may be disclosed or used for treatment and payment of
       health care operations.
      The Practice has the Notice of Privacy Practices and that the patient has the opportunity
       to review this Notice.
      The Practice reserves the right to change the Notice of Privacy Policies.
      The patient has the right to restrict the uses of their information; however, the Practice
       does not have to agree to the restrictions.
      The patient may revoke the Consent in writing at any time and all future disclosures will
       then cease.
      The Practice may condition treatment upon execution of the Consent.

This acknowledgement was signed by _______________________________________________

Relationship to patient (if other than patient) _________________________________________


Date ______/________/_________
       MM       DD        YYYY



Witness (Practice Representative) __________________________________________________
                                                            (Print name)




Date ______/________/_________
       MM       DD        YYYY
              Please fill out this New Patient Information Packet and return the completed document by
              mail, email, or fax. All information must be received in office at least 48 hours prior to your
                          appointment or your appointment will be automatically rescheduled.




                                       FLORI D A NEU ROV ASCU LAR I NSTI TUTE

                                                      Release of Medical Information


5 Tampa General Circle                   Patient Name _____________________________________________
Harbourside Medical                                        First             Middle                Last
Tower, Suite 200
Tampa, FL 33606-3500                     Doctor __________________________________________________

Phone: (813) 250-9101                    Hospital _________________________________________________
Fax: (813) 844-4952
prev entastroke@floridastroke.com
                                         Address _________________________________________________

                                         City ________________________ State _______ Zip ____________

                                         Phone (       )           - _______ Fax (           )     - ______
Erfan A. Albakri, M.D.
  Medical Director                            I AUTHORIZE YOU TO RELEASE CONFIDENTIAL
  Vascular Neuro logy/Stroke               INFORMATION REGARDING MY MEDICAL STATUS TO:

                                         Florida Neurovascular Institute, Erfan A. Albakri, M.D.
Administration:
                                         5 Tampa General Cir. Suite 200
Betty Stewart                            Tampa, FL 33606
 Chief Operating Officer                 Phone (813) 250-9101 Fax (813) 844-4952
Roger Shaw
  Neurodiagnostic Technologist               Physician’s Office Reports
                                             Hospital Medical Records
Andrea Zevchack
  Chief Financial Officer                    Radiology Reports
  Co mp lian ce                              Laboratory Reports
Lis a S teff y
  Ultr aso un d Tech                     Patient Signature __________________________________________
Is aia h An to nek , R .N .
  St r ok e Research Coo r din ato r
                                         Date ______/________/_________
                                                MM         DD        YYYY

                                         Patient Date of Birth ______/________/_________
                                                                   MM       DD        YYYY
Stroke Clinic
Vascular Prevention Clinic               Patient Social Security Number ___________-_________-_________
Headache Clinic
Memory Disorder Clinic
Neuromuscular Clinic
              Please fill out this New Patient Information Packet and return the completed document by
              mail, email, or fax. All information must be received in office at least 48 hours prior to your
                          appointment or your appointment will be automatically rescheduled.




                                       FLORI D A NEU ROV ASCU LAR I NSTI TUTE

                                                      Release of Medical Information

                                         Patient Name _____________________________________________
                                                           First             Middle                Last
5 Tampa General Circle
Harbourside Medical                      Doctor __________________________________________________
Tower, Suite 200
Tampa, FL 33606-3500
                                         Hospital _________________________________________________
Phone: (813) 250-9101
Fax: (813) 844-4952                      Address _________________________________________________
prev entastroke@floridastroke.com
                                         City ________________________ State _______ Zip ____________

                                         Phone (       )           - _______ Fax (           )     - ______

                                              I AUTHORIZE YOU TO RELEASE CONFIDENTIAL
Erfan A. Albakri, M.D.
                                           INFORMATION REGARDING MY MEDICAL STATUS TO:
  Medical Director
  Vascular Neuro logy/Stroke
                                         Florida Neurovascular Institute, Erfan A. Albakri, M.D.
                                         5 Tampa General Cir. Suite 200
Administration:                          Tampa, FL 33606
                                         Phone (813) 250-9101 Fax (813) 844-4952
Betty Stewart
 Chief Operating Officer
                                             Physician’s Office Reports
Roger Shaw                                   Hospital Medical Records
  Neurodiagnostic Technologist
                                             Radiology Reports
Andrea Zevchack                              Laboratory Reports
  Chief Financial Officer
  Co mp lian ce
                                         Patient Signature __________________________________________
Lis a S teff y
  Ultr aso un d Tech

Is aia h An to nek , R .N .              Date ______/________/_________
  St r ok e Research Coo r din ato r            MM         DD        YYYY



                                         Patient Date of Birth ______/________/_________
                                                                   MM       DD        YYYY
Stroke Clinic
Vascular Prevention Clinic
Headache Clinic                          Patient Social Security Number ___________-_________-_________
Memory Disorder Clinic
Neuromuscular Clinic
              Please fill out this New Patient Information Packet and return the completed document by
              mail, email, or fax. All information must be received in office at least 48 hours prior to your
                          appointment or your appointment will be automatically rescheduled.




                                       FLORI D A NEU ROV ASCU LAR I NSTI TUTE

                                                      Release of Medical Information

                                         Patient Name _____________________________________________
                                                           First             Middle                Last
5 Tampa General Circle
Harbourside Medical                      Doctor __________________________________________________
Tower, Suite 200
Tampa, FL 33606-3500
                                         Hospital _________________________________________________
Phone: (813) 250-9101
Fax: (813) 844-4952                      Address _________________________________________________
prev entastroke@floridastroke.com
                                         City ________________________ State _______ Zip ____________

                                         Phone (       )           - _______ Fax (           )     - ______

                                              I AUTHORIZE YOU TO RELEASE CONFIDENTIAL
Erfan A. Albakri, M.D.
                                           INFORMATION REGARDING MY MEDICAL STATUS TO:
  Medical Director
  Vascular Neuro logy/Stroke
                                         Florida Neurovascular Institute, Erfan A. Albakri, M.D.
                                         5 Tampa General Cir. Suite 200
Administration:                          Tampa, FL 33606
                                         Phone (813) 250-9101 Fax (813) 844-4952
Betty Stewart
 Chief Operating Officer
                                             Physician’s Office Reports
Roger Shaw                                   Hospital Medical Records
  Neurodiagnostic Technologist
                                             Radiology Reports
Andrea Zevchack                              Laboratory Reports
  Chief Financial Officer
  Co mp lian ce
                                         Patient Signature __________________________________________
Lis a S teff y
  Ultr aso un d Tech

Is aia h An to nek , R .N .              Date ______/________/_________
  St r ok e Research Coo r din ato r            MM         DD        YYYY



                                         Patient Date of Birth ______/________/_________
                                                                   MM       DD        YYYY
Stroke Clinic
Vascular Prevention Clinic
Headache Clinic                          Patient Social Security Number ___________-_________-_________
Memory Disorder Clinic
Neuromuscular Clinic

								
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