Dear Patient, Norfolk Virginia Beach Chesapeake Suffolk Hampton Kilmarnock Portsmouth Eastern Shore Elizabeth City ALAN L. WAGNER, M.D. F.A.C.S.
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1 ALAN L. WAGNER, M.D. F.A.C.S. KAPIL KAPOOR, M.D. DISEASES & SURGERY OF RETINA & VITREOUS MACULAR DEGENERATION DIABETIC RETINOPATHY RETINAL DETACHMENT ADULT & PEDIATRIC RETINAL SURGERY OCULAR ONCOLOGY / BRACHYTHERAPY INDOCYANINE GREEN ANGIOGRAPHY CLINICAL RESEARCH TRIALS Dear Patient, Our records indicate you have an upcoming scheduled appointment at the Wagner Macula & Retina Center with Alan L. Wagner, M.D., F.A.C.S. or Kapil Kapoor, M.D., who specializes in diseases of the retina and macula. During your time with us we will work as a team to provide the best care for your eyes. To aid in your care, please complete the enclosed forms, items or information listed below and bring to your first visit: Completed medical questionnaire. (Enclosed) Completed Notice of Privacy Practices (Enclosed). This form will allow us to discuss your care only with the authorized names you list, in accordance with Health Insurance Portability and Accountability Act (HIPAA). This form is also an acknowledgment that you have the opportunity to receive the Wagner Macula & Retina Center s Notice of Privacy Practices (NPP). Completed Information Regarding Dilating Eye Drops. (Enclosed) Drivers License or identification card and INSURANCE CARDS. List of your medications Referral - if your insurance requires one. Eyeglasses/Sunglasses.
2 On the day of your first visit, a technician will prepare you to see Dr. Wagner or Dr. Kapoor. During this process your eyes will be dilated. The dilating drops blur your vision and make your eyes sensitive to light for several hours. We encourage patients to bring someone to drive them home. Due to the dilation time and the nature of the examination, your visit may last approximately 2 hours. Please plan accordingly. If you are a diabetic, bring any necessary snacks. If you take medications on a routine time schedule, bring them with you. Due to the type of specialty, our practice encounters emergencies during the day and this may delay the time you are seen by the doctor. We will gladly file your insurance; however, be prepared to pay your copayment at the time of your visit. Payment arrangements can be made or we do offer a 30% discount to patients that pay in full on that date of service. (757) Due to limited seating, we respectfully request that you be accompanied by only one additional family member, friend or assistant. Should you have any further questions or concerns, please feel free to contact our staff at (757) **Two business days prior to your scheduled appointment you will receive an automated call reminding you of your appointment date, time and location.** Sincerely, Alan L. Wagner, M.D., F.A.C.S. Kapil G. Kapoor, M.D. Staff
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4 Do you have or have had any of the following medical problems? Circle Yes or No Diabetes Yes / No Year Diagnosed High Blood Pressure Yes / No Year Diagnosed Heart Condition Yes / No Year Diagnosed Stroke Yes / No Year Diagnosed Cancer Yes / No Year Diagnosed Lung Disease/ Asthma Yes / No Year Diagnosed Skin Disease Yes / No Year Diagnosed Bladder/ Prostate Yes / No Year Diagnosed HENT (head, ear, nose, throat) Yes / No Year Diagnosed Tuberculosis Yes / No Year Diagnosed Thyroid Yes / No Year Diagnosed Gastrointestinal Yes / No Year Diagnosed Neurological Yes / No Year Diagnosed Hematologic/ sickle cell/ anemia/ HIV Yes / No Year Diagnosed Lymphatic/ Lupus Yes / No Year Diagnosed Muscle Skeletal/ Arthritis Yes / No Year Diagnosed Do any members of your family (Mother/ Father/ Siblings etc.) have any of the medical conditions listed above? If so, please specify relationship and condition. Have you ever been diagnosed with any eye diseases? If so, list diagnosis and year diagnosed. Does any family member have history of eye diseases? If so, please list relationship and disease. Have you had any previous eye operations? If so, please list type of operation and the year(s). Have you had any previous operations? If so, please list type of operation and year(s). Do you smoke? Yes / No Do you drink? Yes / No Do you exercise? Yes/ No If so, how much? If so, how much? If so, how much? Do you use illicit substances/ recreational drugs? Yes / No If so, what and how much? OFFICE USE ONLY Above History Reviewed by:
5 Patient Please Complete: List of Medications Dosage Reason for Medication Technician Initials/ Eye Drops or Ointments Dosage Reason for Medication Technician Initials/ Medication Allergies: Food Allergies: Norfolk Virginia Beach Chesapeake Suffolk Hampton Kilmarnock Portsmouth Eastern Shore Elizabeth City
6 Notice of Privacy Practices Wagner Macula & Retina Center The Wagner Macula & Retina Center (WMRC) recognizes that patient information is sensitive and, as such, must be treated carefully and responsibly. A federal regulation, know as HIPAA (Health Insurance Portability and Accountability Act) requires that we provide a detailed notice in writing of our privacy practices. It is the legal duty of WMRC to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care and for other services relating to your health care. The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used by WMRC, as well as reasons why your health information could be sent to other providers outside of our practice. The Notice of Privacy Practices describes your rights in regards to protection of your health information and how you may exercise those rights. It also gives you the names of contacts should you have questions or comments about the policies and procedures. There is a copy of the WMRC Notice of Privacy Practices available in the lobby for the patient or the patient s representative to review. You may also request a copy from the Practice. I (print your name) hereby authorize the discussion of my medical information and diagnosis including results regarding my care with the Wagner Macula & Retina Center with the following people. Name Relationship phone number Name Relationship phone number Name Relationship phone number Patient Acknowledgement I have received and/or had the opportunity to receive the Wagner Macula & Retina Center s Notice of Privacy Practices, which describes the methods for protecting my health information that is used in providing health care services to me. / Patient (or Personal Representative) / Witness Note: WMRC retains this signed page
7 INFORMATION REGARDING DILATING EYE DROPS Dilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye. Dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for your ophthalmologist to predict how much your vision will be affected. Because driving may be difficult immediately after an examination, it s best if you make arrangements not to drive yourself. Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. I hereby authorize Dr. and/or such assistants as may be designated by them to administer dilating eye drops. The eye drops are necessary to diagnose my condition. Patient (or person authorized to sign for patient) Witness
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Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive Florence, Alabama
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive 256-766-0270 Father: DOB: SS#: Home Address: Home #: Work #: Cell #: Employed By: Address: Do you have dental insurance? Yes No
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
San Francisco Ear Nose & Throat Medical Group, Inc
SF ENT San Francisco Ear Nose & Throat Medical Group, Inc Adult & Pediatric Otolaryngology Hearing Disorders Endoscopic Sinus Surgery Head & Neck Surgery Thomas L. Engel, M.D. Vanessa R. Erickson, M.D.
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address: Whom may we thank for referring you to us? Names of
Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305
Patient Information Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305 Home Phone: Cell Phone: Last Name: First Name: MI Mailing Address: APT City/State/Zip Sex: Male Female Birthdate:
NEW PATIENT PAPERWORK
NEW PATIENT PAPERWORK Welcome! Please fill out the necessary paperwork provided. It is our pleasure to serve you and your family. How did you find out about us? If It was a friend or doctor, please list
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
Patient Name Date of Birth / / Today s Date / /
Dr. Mark Valente Dr. Andy Indresano Board Certified, Fellowship Trained Phone. 972.707.0005 Fax. 888.992.6199 DISCspine.com New Patient Intake Form Name First MI Last Street Address Apt # _ City _ State
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Notto Chiropractic Health Center Patient Information
Notto Chiropractic Health Center Patient Information Acct #: Name: Preferred Name: Address: City: State: Zip: Home Phone: ( ) - _. Work Phone: ( ) -. Who Referred You? In Case of Emergency: Phone Number:
HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**
Name: Date: D.O.B: HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU** PAST MEDICAL HISTORY: Anxiety Arthritis Asthma A-Fib BPH Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
Vision/Lifestyle Questionnaire
Roger J. Meyer, M.D. Retina Fellowship Trained Macular Degeneration Diabetic Eye Care Glaucoma Robert M. Reinauer, M.D. Retina Fellowship Trained Surgical/Medical Treatment of the Retina & Vitreous Macular