Patient Information. Name Date of Birth Age. Address. (Street Apt City State Zip) Social Security Number - - Home Phone - - Marital Status
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1 Patient Infrmatin Name Date f Birth Age (First Middle Last) Address (Street Apt City State Zip) Scial Security Number - - Hme Phne - - Marital Status Male Female Cell Phne - - Name f Spuse r Parent (if a minr): Cntact s Phne #: Emplyed By: Business Address: Occupatin: Phne #: Insurance Infrmatin Primary: ID#: Grup #: Secndary: ID#: Grup #: Referrals Referred By: Family Physician: Phne #: Address: Phne#: Pharmacy Infrmatin: Phne: Fax:
2 Is this a WORK RELATED injury? Y/N Date f Injury: Is this an AUTO ACCIDENT RELATED injury? Y/N Date f accident: Adjuster s name: Phne #: Aut Insurance Cmpany: Claim #: Phne #: Aut Insurance Address: Privacy Plicy By signing this frm, I acknwledge that I have reviewed a cpy f Suth Atlanta Neursurgery s ntice f privacy plicies. I understand that a cpy f the plicy is available n ur website ( r by request at ur ffice. Cash Check Methd f Payment fr Tday s Services PLEASE READ: ALL CHARGES ARE DUE AT THE TIME OF SERVICE. WE DO NOT FILE INSURANCE FOR OFFICE VISITS UNLESS YOU HAVE A CONTRACTED INSURANCE COMPANY WITH THIS OFFICE. CO-PAY FEES ARE DUE AT THE TIME OF EACH OFFICE VISIT. ALL PROFESSIONAL SERVIDCES RENDERED ARE CHARGED TO THE PATIENT REGARDLESS OF INSURANCE COVERAGE. THERE IS A $40.00 CHARGE FOR EACH FORM COMPLETED IN THIS OFFICE. ALLOW 3-5 BUSINESS DAYS FOR COMPLETION. THERE IS A $35.00 CHARGE FOR ALL RETURNED CHECKS. INSURANCE AUTHORIZATION AND ASSIGNMENT: I HEREBY AUTHORIZE SOUTH ATLANTA NEUROSURGERY, P.C. TO FURNISH INFORMATION TO INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENT AND I HEREBY ASSIGN TO THE PHYSICIAN ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO MYSELF OR DEPENDENTS. I UNDERSTAND I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY MY INSURANCE. I DO HEREBY GIVE AUTHORIZATION TO SOUTH ATLANTA NEUROSURGERY, P.C. TO TREAT AND EXAMINE THE ABOVE NAMED PATIENT. SIGNATURE: RELATIONSHIP TO PATIENT:
3 AllSpine Laser and Surgery Center/Suth Atlanta Neursurgery Shahram Rezaiamiri, MD, FACS Rbert Friedman, MD, FACS Harld Trxler, DO Saeed Salles, MD, PhD Sctt Linacre, PA-C, MMSc Phne: Fax: We have fur cnvenient lcatins: Stckbridge: Fayetteville: 900 Eagles Landing Pkwy 1267 Hwy 54 W, #5200 Stckbridge, GA Fayetteville, GA Riverdale: Newnan: 33 Upper Riverdale Rd. Ste Hwy 34 East, Suite 103 Riverdale, GA Newnan, GA T ur valued patients and their families: Welcme t ur practice. We strive t prvide the highest quality medical and surgical care and t reach ut gal we need yur cperatin. Please read the fllwing infrmatin t get familiar with ur practice, and if yu have any questins, please d nt hesitate t ask. Allspine Surgery Center is a ne-stp-shp fr all spine care. Frm evaluating patients with the mst basic cnditins such as a simple back spasm t the mst cmplex surgical cnditins such as spinal crd cmpressin and tumrs. We cver the entire spectrum f spinal diseases. Our team f experts includes: A Neursurgen with expertise in minimally invasive surgeries (Neck and Back), Gamma Knife and Laser Surgery. An Interventinal Spine & Pain Management Specialist with expertise in spine and jint injectins, kyphplasty, spinal crd stimulatrs and ther nnsurgical treatments.
4 An exceptinal Physician Assistant that has been with us since A Registered Nurse with perating rm experience and a lve fr patients. Our Missin: Our missin is t help every patient in the least invasive and mst effective way pssible t imprve quality f life. We strive fr curteus and prfessinal service in rder t make the patient s experience as pleasant as pssible. Our Pledge: We pledge t treat ur patients like ur wn Family; with Ultimate Respect. We pledge t perate with Hnesty and Transparency. We pledge t Infrm & Educate ur patients abut all f their treatment ptins and pssible utcmes. S that we can better service yu please nte the fllwing: N cell phnes r small children (under 12 years f age) are allwed in the exam rm. Prescriptins will be refilled during the ffice hurs ONLY. N prescriptins will be phned in after the ffice has clsed. Pain medicatin is t be taken as prescribed. Imprper use f medicatins can lead t the terminatin f the physician-patient relatinship. We require a 24-hur advance ntice fr prescriptin refills. If yu d nt shw up fr the appintment and have nt ntified ur ffice at least 24 hurs in advance, yu have t discuss the case with ur ffice manager t be cnsidered fr anther appintment. We d nt cmplete disability frms (except fr a shrt perid fr thse pending surgery). Pst-perative patients: Disability frms will be cmpleted very accurately and hnestly; regardless f hw lng yu have been n disability. If yu have any questins r cncerns, please raise the issue and it will be dealt with prmptly. Sincerely yurs, Practice Management I have read and understand the abve infrmatin: (Patient signature)
5 AllSpine Laser and Surgery Center/Suth Atlanta Neursurgery Shahram Rezaiamiri, MD, FACS Rbert Friedman, MD, FACS Harld Trxler, DO Saeed Salles, MD, PhD Sctt Linacre, PA-C, MMSc Phne: Fax: I understand that I am entering int a cntractual relatinship with AllSpine Surgery Center/Suth Atlanta Neursurgery fr prfessinal care. I further understand that merit less and frivlus claims fr medical practice have an adverse affect upn the cst and availability f medical care and may result in irreparable harm t the medical prvider. As additinal cnsideratin fr prfessinal care prvided t me by medical practice/physician, I r my representative agree nt t advance, directly r indirectly, any false, merit less, and I r frivlus claims f medical malpractice against AllSpine Surgery Center. Furthermre, shuld a meritrius medical malpractice case r cause f actin be initiated r pursued, I r my representative agree t use ABMS bard-certified expert medical witness in the same r similar specialty. Furthermre, I agree these expert witnesses will adhere t the guidelines and/r cde f cnduct defined by specialty scieties fr expert witnesses in the area(s) f medicine that wuld typically have the backgrund and experience t pine n such case. In further cnsideratin fr this, Dr. Rezaiamiri agree t the same stipulatins. (Shahram Rezaiamiri, MD, FACS) (Patient)
6 Patient Name: 1. Please state the main reasn yu are here tday. What is the main cmplaint? 2. Hw lng have yu had these symptms? 3. Are these symptms getting wrse lately? Are they prgressively getting wrse? 4. Please list yur medical prblems: Please list any surgeries yu have had: Please list any medicatins yu are taking nw: D yu smke? Y/N If s, hw much? If yu quit smking, when was that? 8. D yu presently use r have used illicit drugs such as ccaine? 9. D yu drink Alchl? Y/N If s, hw much? 10. Please circle any f the fllwing symptms yu have nw: Palpitatins Pr appetite Cnstipatin Chest pain Weight lss Muscle cramps Back pain Syncpe Feet swelling Headaches Anxiety Jint stiffness Feeling ht r cld Hearing prblems Urinary symptms Neck pain Cugh Jint swelling Diarrhea Shrtness f breath Weight gain Visin prblems
7 Name: If yu have neck r arm pain, answer the fllwing questins: Circle all that apply: Hw lng d yu experience neck pain? I have neck pain mre than I d arm pain. I have arm pain mre than I d neck pain. Hw lng have yu had the arm pain? I have pain in the left arm. I have pain in the right arm. I have mre pain in the left arm than I d the right arm. I have mre pain in the right arm than I d the left arm. What makes yur neck pain wrse? What eases yur neck pain? What makes yur arm pain wrse? What eases yur arm pain? Circle the test(s) that yu have already received: MRI CAT scan Myelgram Plan X-rays Circle all that apply: I have weakness in my arms Left/Right/Bth My handwriting is getting wrse lately My balance is getting wrse lately I have difficulty with buttning my shirts I have been drpping bjects lately I have numbness in my: arms/hands/bth Circle all that apply: Hw lng d yu experience back pain? I have back pain mre than I d leg pain. I have leg pain mre than I d back pain. Hw lng have yu had leg pain? I have pain in the left leg. I have pain in the right leg. I have mre pain in the left leg than I d the right leg. I have mre pain in the right leg than I d the left leg. What makes yur pain wrse? Laying dwn / Sitting / Standing up / Walking What eases yur back pain? Laying dwn / Sitting / Standing up / Walking What makes yur leg pain wrse? Laying dwn / Sitting / Standing up / Walking Circle the test(s) that yu have already received: MRI CAT scan Myelgram Plan X-rays
8 Name: Please list any treatments yu have had: 1. Physical Therapy: What fr? Dates: Hw lng? 2. Chirpractr: What fr? Dates: Hw lng? 3. Pain Management: What fr? Dates: Hw lng? 4. Injectins: What fr? Dates: Hw lng: 5. Tractin: What fr? Dates: Hw lng? 6. Other: What fr? Dates: Hw lng? Please indicate frm zer t ten, hw bad yur sexual life has been affected by the pain that yu have been experiencing: Nt affected=0 10=severely affected Please indicate frm zer t ten, hw much back pain yu are experiencing: Nt affected=0 10=severely affected Please indicate frm zer t ten, hw much leg pain yu are experiencing: Nt affected=0 10=severely affected Please indicate frm zer t ten, hw much neck pain yu are experiencing: Nt affected=0 10=severely affected Please indicate frm zer t ten, hw much arm pain yu are experiencing: Nt affected=0 10=severely affected
9 AllSpine Surgery Center Shahram Rezaiamiri, MD, FACS Rbert Friedman, MD, FACS Harld Trxler, DO Saeed Salles, MD, PhD Sctt Linacre, PA-C, MMSc Name: Please mark n the figure the area that yu have pain n yur bdy:
10
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