CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) INTERNET
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1 CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) INTERNET MARTIN V.T. TON, MD This is very important information about your appointment. Please take the time to read and follow the instructions carefully. Dear : Kindly complete the enclosed forms and bring them with you to your appointment on (PLEASE DO NOT MAIL FORMS) at with Dr. Ton. Please arrive at the office at. We are located in the 1080 Medical Office Building, 1080 First Colonial Rd Suite 201 Virginia Beach, VA Please note: Your appointment requires: Nothing to eat or drink hours prior to your procedure. Someone must be present and remain in office during procedure to drive you home. Please call us at at least 24 hours in advance if you cannot make your appointment or this will result in a missed appointment charge of $60. If the directions are unclear in any way, please do not hesitate to call us or visit our website at Thank you. Additional Instructions: -Please bring insurance cards and ID. -You will need to obtain copies of any radiology films or discs (X-ray, MRI or CT) unless they were taken at a Sentara facility or MRI & CT diagnostics. -There is a fee for non medical forms such as disability or leave forms $50 for the first side $15 for each additional side **Please note: You should take all heart and blood pressure medication with a sip of water at the usual time in the morning before your appointment A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 1
2 Consultants in Pain Medicine, Inc. **MEDICATION GUIDELINES PRIOR TO PROCEDURES Please continue to take all your regular (ie. blood pressure) medications on the day of your appointment EXCEPT: Blood Thinners (anticoagulants): DO NOT STOP ANY ANTICOAGULANTS WITHOUT THE AUTHORIZATION OF YOUR PRESCRIBING DOCTOR. Most of our procedures will require that you stop your anticoagulants using these guidelines. Aspirin -IF PRESCRIBED BY YOUR DOCTOR, you must obtain their authorization before stopping, otherwise stop 6 days prior to your procedure Coumadin - stop 5 days before your procedure. Heparin - contact the office for specific directions. Plavix (Clopridogrel) stop for 7 days prior to your procedure. Pletal-stop 5 days prior to your procedure Ticlid (Ticlopidine)- stop for 14 days prior to your procedure. Arixtra ( Fondaparinux)-stop 4 days prior to your procedure. Effient (Prasugrel) -stop 10 days prior to your procedure. Pradaxa (Dabigatran)-stop 5 days prior to your procedure. Brilinta (Ticagrelor)- stop 5 days prior to your procedure. Xarelto-(Rivaroxaban) stop 3 days prior to your procedure. Aggrenox-stop 7 days prior to your procedure. Eliquis-(Apaxiban) stop 5 days prior to your procedure Lovenox- stop 24 hours prior to your procedure Please carefully review the contents of your current medications because many over the counter drugs and herbal supplements contain aspirin (acetylsalicylic acid): Aggrenox (aspirin/dipyridamole), Anacin, Bayer (including Back and Body Pain formula), BC Powder, Bexophene, Bufferin, Darvon Compound, Ecotrin, Excedrin, Fiorinal (butalbital/aspirin), Goody s, Percodan, Norgesic and Stanback. Please contact our office or visit our website at if you have questions. A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 2
3 DIRECTIONS TO 1080 MEDICAL OFFICE BUILDING From Interstates 64 and 664: Take 264E to exit 21B (2 nd of two First Colonial Rd exits). Once on First Colonial Rd, go about 1.5 miles to 1080 First Colonial Rd, located just past Virginia Beach General Hospital. Turn Right on Old Donation Parkway to access the parking lot. Use the second building entrance that is closest to the hospital. We are located on the 2 nd floor in Suite 201. From Chesapeake Bay Bridge Tunnel: After exiting bridge stay in right lane and follow sign towards Beaches/ Shore Dr. Turn left at light onto Shore Dr. Cross the Lesner Bridge. At the 4th traffic light turn right on N. Great Neck Rd. Travel approx. 5 miles and then turn left on First Colonial Rd (Exxon Station on corner). At 2 nd traffic light make a left onto Old Donation Parkway. Make the first right into the parking lot for the 1080 Medical Office Building. Use the second building entrance that is closest to the hospital. We are located on the 2 nd floor in Suite 201. A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 3
4 CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) MARTIN V.T. TON, MD Welcome to Consultants in Pain Medicine. Our physician, nurses and office staff hope to provide the best care possible with regard to your particular pain condition. Please fill out the enclosed questionnaire and answer all questions as completely as possible. Bring the completed forms to your appointment. (Please do not mail forms back to our office.) Your information is very important for proper treatment. Thank you. Consultants in Pain Medicine A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 4
5 Consultants in Pain Medicine, Inc. Please remember your fasting and medication instructions. If you have not received this information, please call the office at or visit M.D. Signature Date Name: Age Height Weight Vitals: BP HR RR T SaO2 (will be completed at consultation) Please mark exactly where your pain is located: ALLERGY: When did you first notice your pain:_ Did you injure yourself, if so, what was the nature of your injury: Please describe what your pain feels like: Please mark any of the following that help describe your pain: Continuous Shooting Burning Sharp Tearing Off and On Dull Toothache Pulling Knife like PLEASE RATE YOUR PAIN BELOW What makes your pain WORSE: What makes your pain BETTER (mark ALL that apply): Rest Sitting Lying down Standing Nothing at all OTHER: A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 5
6 Please remember your fasting and medication instructions. If you have not received this information, please call the office at or visit Do you have numbness in your arms or legs: No Yes Do you get tingling in your arms or legs: No Yes Do you have weakness in your arms or legs: No Yes Since your pain began, have you lost TOTAL control of your bowel or bladder? What medications have you taken BEFORE and stopped: Please indicate if you have had the following treatments for your pain: Epidural Steroid Injection Physical Therapy Chiropractor Acupuncture Trigger Point Injections OTHER: Which has helped your pain: Please indicate if you have had the following tests for your pain: MRI CT Scan Electromyelogram / EMG Bone Scan X-Rays Which other doctors do you see: Please mark all illnesses and disorders for which you are being treated or followed by a doctor: High Blood Pressure Diabetes Liver disease/hepatitis Heart Attack Underactive Thyroid Kidney Failure Congestive Heart Failure Overactive Thyroid Dialysis Irregular Heart Beat Tuberculosis Urine Infections Blocked Carotid Artery Pneumonia Kidney Stones Poor Circulation Asthma Seizures Cancer Heartburn Stroke Depression Acid Reflux HIV / AIDS OTHER: Please indicate all SURGERIES you have had: Lumbar /Back Heart Bypass Hysterectomy Neck Lung Caesarian Section Gallbladder Removal Aortic Aneurysm Repair Tubal Ligation Appendix Removal Carotid Artery Repair Brain Tonsil Removal Leg Artery Bypass Bowel Removal Bladder Kidney Stone Exploration of Bowel Broken Bone Cataract Prostate OTHER: A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 6
7 Please remember your fasting and medication instructions. If you have not received this information, please call the office at or visit Please list all your current MEDICATIONS and doses: DRUG DOSE Please list all drug ALLERGIES: Are you taking any BLOOD THINNING MEDICATIONS: Yes No What is your current occupation: Does it involve lifting or bending: Are you currently out of work on disability: Do you consume more than 7 alcoholic drinks per week, or more than 3 per occasion: No Yes Would you like information on alcohol consumption cessation: No Yes Do you consume tobacco: No Yes Would you like information on tobacoo consumption cessation: No Yes Do you use recreational drugs: Is your mother or father deceased, if so from what illness and at what age: Do you have any brothers or sisters, please list their ages:_ Has anyone in your immediate family had a similar medical problem as the one that has brought you here today: Do you currently have any of these symptoms: Severe weight loss Seizure Very easy bruising Very high fever Stroke Excessive bleeding Night sweating Passing out Suicidal Thoughts Nausea / Vomiting Chest Pain Hallucinations Diarrhea Heart Palpitations Constipation Irregular Heartbeat Loss urine control Chronic cough OTHER: Constant Urination Wheezing Painful Urination Bloody Sputum Additional Information: A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 7
8 . CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) MARTIN V.T. TON, MD PATIENT: DOB: I hereby give Consultants in Pain Medicine my permission to request and receive any and all medical information from any previous or referring doctors. SIGNATURE DATE A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 8
9 Prescriptions: If you wish for us to write prescriptions for you, we will need your pharmacy information as follows: PHARMACY NAME: STREET ADDRESS: CITY: PHONE NUMBER: FAX NUMBER: A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 9
10 CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) WEBSITE- MARTIN V. T. TON, M.D. Date: Patient: Insurance: Our records show that you have the insurance listed above. If this is not correct, please contact our office immediately with the correct information. Please remember to bring your insurance cards and picture ID to your appointment with Dr. Ton. If your insurance company requires an insurance referral, please make sure that your primary care physician or referring physician issues all the necessary referrals to our office prior to your scheduled appointment. Please be advised that Consultants in Pain Medicine bills for Dr. Ton s professional services only. We are considered and outpatient facility with Sentara Virginia Beach General Hospital and you will receive a separate bill from the facility. These charges are for the facility, radiology tech and equipment and medication used for your appointment. Your visit will be billed as an outpatient service. If you have any questions or concerns regarding your insurance, please call our billing office at Thank you in advance for you payment for services rendered. (cash, check, visa and mastercard are accepted) Patient signature date A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 10
11 CONSULTANTS IN PAIN MEDICINE ATLANTIC ANESTHESIA, INC. ACKNOWLEGDEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I have been provided with a copy of Consultants in Pain Medicine/Atlantic Anesthesia, Inc. and its subsidiaries (AAI) Notice of Privacy Practices ( Notice ): It tells me how AAI will use my health information for the purposes of my treatment, payment for my treatment, and AAI s health care operations. The Notice explains in more detail how AAI may use and share my health information for other than treatment, payment, and health care operations. AAI will also use and share my health information as required/permitted by law. I have declined to receive a written copy of the Notice for Privacy Practices. (Initial) Patient s Complete Legal Name: (Please print) Patient s DOB: Today s Date: Signature: (Patient or legal representative*) *May be requested to show proof of representative status HIPPA Document Retain for minimum of 6 years A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 11
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PATIENT INFORMATION Please print clearly and complete all blanks
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