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					Laila Hirjee, M.D. P A                                   5617 Belmont Ave        Suite 103-D Dallas, Tx       75206    Ph: 214-824-3333         Fax: 214-824-3131

                                                                New Patient Information
** PLEASE UNDERSTAND THAT LAILA HIRJEE, M.D. WILL NOT BE ABLE TO SCHEDULE PATIENT AN
   APPOINTMENT UNTIL ALL INSURANCE IS VERIFIED AND COPIES OF CARDS ARE OBTAINED**
Today’s Date _____________                        Facility Name ___________________________________                                        Room #______________

Patient’s Last Name ___________________First________________Middle Initial_____ Home Phone_______________

Patient’s Address             _______________________________City___________________State________Zip Code__________

Patient’s SSN_________________________ Sex                                  □ Male □ Female                         Date of Birth______________________

Marital Status          M      D       W      S          Pharmacy Name / Phone Number_____________________________________

Current Home Health Agency or CBA Organization You Are Using__________________________________________

Please List ALL Allergies to Medicine or Food____________________________________________________
___________________________________________________________________________________________

Are You A DNR                      □    Yes □            No              Do You Have A Living Will                          □     Yes       □     No

Would you like more information regarding Advanced Directives?                                                              □     Yes       □     No

                                                         INSURANCE INFORMATION
       PLEASE HAVE YOUR INSURANCE CARD SO WE MAY MAKE A COPY FOR OUR RECORDS

Medicare Number____________________________________ (Medicare must contain Medicare Part B Coverage)

Secondary Insurance Name___________________________ Policy ID#________________ Group #______________

Secondary Insurance Address___________________________________________Phone#_______________________

Name of Policy Holder of Secondary Insurance_________________________Relationship To Patient____________

            RESPONSIBLE FINANCIAL PARTY ( PLEASE FILL OUT COMPLETELY)
Name _________________________________                                 Address_________________________________________________

City_____________________________________ State_______________________ Zip Code__________________

Relationship _______________________________________________ Use as emergency contact? □ Yes or □ No

Home Number____________________ Work Number________________________ Cell Phone________________

Power Of Attorney Name:________________________________________ Phone #___________________________

                                                    PREVIOUS PHYSICIAN INFORMATION
Current Primary Physician______________________________________________ Phone Number______________
Address__________________________________________________________________________________________
My Hospital Of Choice Is___________________________________________________________________________
______ (initial) I do hereby give my permission and consent for medical treatment by Laila Hirjee, M.D. PA
______ (initial) ) I understand that I will be financially responsible for payment of services if Medicare or other insurance denies payment..
______ (initial) I agree to be financially responsible for any testing or treatment ordered by the doctor that may not be considered by my insurance company to be medically
necessary.


_____________________________________________________________                                                              ________________________
Signature                                                                                                                  Date
Laila Hirjee, M.D. P A               5617 Belmont Ave   Suite 103-D      Dallas, Tx 75206     Ph: 214-824-3333 Fax: 214-824-3131



                                Authorization for Release of Medical Health Information
                                     (In compliance with HIPPA this does not authorize release of Psychotherapy Information)


I hereby authorize
_____________________________________________________________________________________________________________________________
                                                  (Entity/Person from Whom Records are Requested)
_______________________________________________________________________________________________________________________________________

to disclose my individual identifiable health information as described below, which may include information concerning communicable diseases such as Human
Immunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”), mental illness (except for psychotherapy notes), chemical or alcohol
dependency, laboratory test results, medical history, treatment, or any other such related information. I understand that this authorization is voluntary and I may
refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form.

I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider; the released
information may no longer be protected by federal and state privacy regulations.

_______________________________________                                     ________________                           _____________________
Patient’s Name                                                              Patient’s DOB                              Patient’s SSN
Date(s) of service (if
known):___________________________________________________________________________________________________________________

Description of Information To Be Released: (check all that apply)

□ Entire Medical Record                           □ Prescriptions
□ Medical History, Examination, Reports           □ Hospital Records Including Reports
□ Allergy Records                                 □ Laboratory Reports
□ Consultations                                   □ Immunizations
□ Surgical Reports                                □ X-ray Reports
□ Treatment or Tests                              □ Billing and Payment Information
□ Other (be
specific):__________________________________________________________________________________________________________

Description of the purpose of the use and/or disclosure:

_________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

The health information described herein shall be released to: _____Hospital; __X__ Physician; _____Insurance Company; _____
Attorney; _____Patient; _____Other (check the appropriate category)

Please Release The Information To The Following Physician:

Laila Hirjee, M.D. PA 5617 Belmont Ave Suite 103-D Dallas Texas 75206                                                   214-824-3333             214-824-3131__
(Physician Name)                (Address)                                         (City)          (State)   (ZIP)             (Phone)                   (Fax)



I understand that this authorization will expire by law in 180 days from the date of this authorization unless I otherwise specify. I
desire this authorization to be in effect until ___________________________________.
                                                                 (expiration event/date)

I further understand that I may revoke this authorization at any time by notifying____________________________________ in
writing at __________________________________________________. I also understand that the written revocation must be
signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken
before the receipt of the written revocation.


___________________________________________                                                       __________________________
Signature of Patient or Patient’s Representative                                                  Date

___________________________________________
Printed Name of Patient’s Representative

___________________________________________                                                       ___________________________________________
Relationship to Patient                                                                           Legal Authority (attach supporting documentation)
Laila Hirjee, M.D. P A                5617 Belmont Ave   Suite 103-D Dallas, Tx   75206   Ph: 214-824-3333   Fax: 214-824-3131




            Permission To Use And Disclose Protected Health Information


Under the Health Insurance Portability and Accountability Act of 1996, as amended, I understand that I have
the right to determine whether or not I wish to have my protected health information (PHI) given out
throughout the course of my treatment with Laila Hirjee, M.D. PA. The PHI listed in my medical records
may include: my name, location, insurance information, a brief description of my medical condition (i.e.,
course of treatment, physician visits, medications, prescriptions, diagnostic testing and results, referral’s for
miscellaneous specialists, Home Health Agency Information, DME paperwork, past history, etc.) I
understand that I have the right to ask that such information not be given to other non-medical entities or
family members or anyone other than myself. I have indicated my choice below.




□  I DO wish my information to be given when questioned to other non-medical entities, family members,
or anyone pertaining to that need per my doctor’s request.


□   I DO NOT wish my information to be given to anyone.




Printed Name_______________________________________________________________________________

Patient Signature________________________________________________________ Date_______________

Relationship if not patient_____________________________________________________________________

Patient’s Date of Birth______________________________ Patient’s SS#______________________________

Patient’s Address____________________________________________________________________________



If option can only be communicated orally by patient, then show it was recorded by:

Printed Name__________________________________________________                            Phone______________________

Signature______________________________________________________                            Date_______________________

Department/Title____________________________________________________________________________
Laila Hirjee, M.D. P A         5617 Belmont Ave   Suite 103-D Dallas, Tx   75206   Ph: 214-824-3333   Fax: 214-824-3131




                                                  DNR


Are You A DNR                                                               □       Yes                  □        No



                                          Living Will

Do You Have A Living Will                                                   □       Yes                  □       No




                                 Advanced Directives


Would you like more information                                             □       Yes                  □       No
regarding Advanced Directives?




_____________________________________________________________                       ________________________
Printed Name                                                                         Date

_____________________________________________________________                       ________________________
Signature                                                                           Date
       Laila Hirjee, M.D. PA         5617 Belmont Ave Suite 103 D Dallas Tx 75206
                                        Phone 214.824.3333 Fax 214.824.3131




I acknowledge that I have received a copy of the above Laila Hirjee, M.D. P A HIPAA Notification of
Privacy Practices and understand it’s contents therein.




_____________________________________________                 _________________
Patient Name (Printed)                                        Date




_____________________________________________                 _________________
Patient Signature                                             Date




             5617 Belmont Ave Suite 103-D Dallas, Tx 75206      Phone: 214-824-3333 Fax: 214-824-3131
    Curriculum Vitae

Laila Hirjee, M.D.                         56 17 Belmont Ave Suite 103-D Dallas, Tx 7 52 0 6 Phone : 214–824–33 33 Fax:: 214 -824-3131




Board Certification:      1997      Board Certified Internal Medicine


Professional Experience   2004 – Current           Private Practice – Internal Medicine
                          2003 – 2004              Doctor’s Home Visits
                          1998-2002                Joel Wilkerson, M.D. Private Practice
                                                   Internal Medicine
                                                   Washington, D.C.

                          1997 – 1998             Fellow, Nephrology N.Y.U.
                                                  Medical Center
                                                  New York, NY

                          1995 – 1997             Resident, Internal Medicine (Chief Resident)
                                                  Sisters of Charity Hospital
                                                  Buffalo, NY

                          1994 – 1995             Resident, Internal Medicine
                                                  St. Luke’s Hospital – Roosevelt Division
                                                  Manhattan, NY

                          1992 – 1994             Medical Officer
                                                  P.I.M.S
                                                  Islamabad, Pakistan

                          1991 – 1990             M.B., B.S. (Bachelor of Medicine &
                                                  Bachelor of Surgery
                                                  Dow Medical College
                                                  Karachi, Pakistan


Honors & Awards              1990          Graduated top 3%
                             1990          13th Position (top 1 percentile) on first M.B.B.S. exam
                             1990          Placed in First Division (Grade A)
                             1990          Top 10% throughout Academic Career

Hospital Privileges
                             LakePointe Medical Center
                              Select Specialty Hospital
Licensure &                  Licensed Physician – State of Texas
Certification                Licensed Physician – District of Columbia
                             BLS & ACLS
                             Board Certified – Internal Medicine
Membership &   American Medical Association
Associations   American College of Physicians
               Texas Medical Association
               Metropolitan Who’s Who Association
               LakePointe Medical Center 2007 Circle of Excellence


Personal       Date of Birth:    October 30, 1966
               Gender:           Female
               Marital Status:   Married
               Hobbies:          Movies, Music and Reading

References:    Excellent References Available Upon Request
     Laila Hirjee, M.D. PA 5617 Belmont Ave Suite 103 D Dallas Tx 75206
                              Phone 214.824.3333 Fax 214.824.3131




               Home Health Agency Preferred Provider
                          Consent Form

Please check the box that applies best for you.


  If in the event that the patient needs home health


       I prefer _________________________________home health agency if
        I / family member needs home health.




       I prefer for Dr. Hirjee / Facility to send whichever home health agency
        that will best match my / family members home health needs.




  ________________________________________________
  Printed Name


  ________________________________________________
  Signature                              Date
                                     Laila Hirjee, M.D. P A
                                             Medical History
PAST MEDICAL HISTORY                   Do you now or have YOU ever had any of the following illness,
CHECK ALL THAT APPLY
CANCER                                   LIVER                                       NEUROLOGICAL
_____Colon Cancer                        _____Cirrhosis                              _____Stroke
_____Esophageal Cancer                   _____Hepatitis A                            _____Seizures
_____Stomach Cancer                      _____ Hepatitis B                           _____ Migraines
_____Breast Cancer                       _____ Hepatitis C                           _____ Other Headache
_____Pancreatic Cancer                   _____Jaundice
_____Endometrial Cancer                  _____Fatty Liver
_____Liver Cancer
_____Leukemia
_____Lymphoma
Other_____________________________       Other_____________________________          Other_____________________________
RENAL                                    HEART                                       RESPIRATORY
_____Kidney Stones                       _____High Blood Pressure (Hypertension)     _____COPD (Emphysema)
_____Kidney Failure                      _____Heart Attack                           _____Asthma
_____Dialysis                            _____Angina                                 _____Tuberculosis (TB)
                                         _____Congestive Heart Failure               _____Sleep Apnea
Other_____________________________       _____Premature Heart Disease                _____Collapsed Lung
                                         _____Palpitations                           Other_______________________________
                                         _____Mitral Valve Prolapse
PSYCHOLOGICAL                            _____Elevated Cholesterol
_____Bipolar                             _____Rheumatic Fever                        ENDOCRINOLOGY
_____Anxiety                             _____Heart Valve Disease                    _____Diabetes, Type I (insulin needed)
_____Depression                          _____Endocarditis                           _____ Diabetes, Type II (pills needed)
_____Obsessive Compulsive Disorder       Other_____________________________          _____Thyroid Disease
_____Schizophrenia                                                                   _____Hypothyroid
Other_____________________________                                                   _____Hyperthyroid
                                                                                     Other_____________________________
MUSCULOSKELETAL                          BLOOD                                       GASTROINTESTINAL
_____Fibromyalgia                        _____VonWillebrands’                        _____IBS – Irritable Bowel Syndrome
_____OsteoArthritis                      _____Hemophillia                            _____Diverticulitis
_____Rheumatoid Arthritis                _____Bleeding or clotting abnormalities     _____Diverticulosis
_____Raynaud’s                           Other____________________________           _____Peptic Ulcer Disease
_____Lupus                                                                           _____Angiodysplasia of GI tract
_____Scleroderma                         INTEGUMENTARY                               _____Gallstones
_____Gout                                _____Eczema                                 _____Hoarseness
Other_____________________________       _____Skin Cancer                            _____Reflux Esophagitis
                                         _____Melanoma                               _____IBD-Chrohn’s
                                         _____Psoriasis                              _____IBD-Ulcerative Colitis
                                                                                     _____Pancreatitis
                                         Other_____________________________          Other______________________________


PAST SURGICAL HISTORY                Please Indicate The Year of any surgeries you have had
                  Laila Hirjee, M.D. P A
                     Medication History

Medication Name     Dosage     Times/Day   Comments
E     veryday tasks becoming a problem? Are you having trouble recalling words, concentrating, naming

objects, understanding commands, performing familiar actions such as word recognition or comprehending
speech? These are just some of the signs to look for. Did you know that Alzheimer’s disease is one of the
most common medical diseases in the elderly today? Causing cognitive impairment and a decline in mental
status, it puts a substantial financial as well as mental burden on families across our country. Although the
diagnosis of Alzheimer’s disease is often missed or delayed, the diagnosis can usually be made using
standardized clinical criteria. In most cases it can be diagnosed and managed in primary care settings such
as in the home or Assisted Living Facilities. Alzheimer’s disease is progressive and irreversible, but
prescription drug therapies for cognitive impairment and for the behavioral problems associated with
dementia can help to enhance a patient’s quality of life. Psychological therapy intervention with family
members can also be beneficial when indicated, as nearly half of all caregivers themselves become depressed
when dealing with a family member with Alzheimer’s. New breakthrough medical treatments and
pharmacological advances are being made every day to ensure that patients have the very best chances of
living their lives more independently, healthier and longer than ever before. If you or someone you know
thinks you may have the signs of Alzheimer’s, please make an appointment with your physician today. It
could make a world of difference to the ones you love. My goal as a physician is to maintain the very best
quality of life for a patient and I strive to do my best to reach that goal with every patient I meet.



                                   Board Certified In Internal Medicine

               GOALS
                                                                                SERVICES OFFERED
       Maximize quality of life
                                                                                 In Home Podiatry
      Maintain resident’s health
                                                                           In Home Mobile Lab and X-ray
       Minimize hospital visits
                                                                               Cardiovascular Testing
       Minimize number of falls
                                                                          Skilled Nursing, Physical Therapy
                                                                                       YOUR YEARS ”
 Maintain positive communication with
                                                                               Occupational Therapy & Much
           resident & family
                                                                                     More…



         5617 Belmont Ave Suite 103-D Dallas, TX 75206 Phone: 214.824.3333 Fax: 214.824.3131

				
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