Office Policy for New Patients

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Transcription:

Office Policy for New Patients Thank you for contacting us for your medical needs. We are glad you have entrusted us to be your medical provider. We are enclosing a few guidelines to help you transition your care to us because we have a very high demand for patients to get into our system, and this helps us to be considerate of everyone s time. 1. It is essential that you bring the enclosed new patient information sheet COMPLETED AND SIGNED with you to the office for your first visit. Without this information we cannot properly register you or set up your chart. 2. We require your insurance cards along with a photo ID to protect your medical identity. 3. The Health Questionnaire is an essential part of your medical record with us and a requirement for the provider to have prior to beginning any treatment for you. Therefore, it is essential that you bring this COMPLETED AND SIGNED. Please do not plan to complete this paperwork in the lobby prior to your visit, as there will not be enough time. Even when you have completed this essential information, it will be necessary that you arrive at our clinic 30 minutes before your scheduled appointment time so that we will be able to enter your information and establish a complete chart. In consideration of your time with our provider and the appointment times of other patients; our expectation is that you will show up early. 1. If you do not arrive early for your initial appointment, we will reschedule your appointment only one more time. If you again do not arrive early, you will not be eligible for any further appointments with our provider group. 2. If you no-show your first appointment, we will schedule one more visit for you. However, if you no-show a second time, you will not be eligible for any further appointments with our providers. (Please see no-show policy for all subsequent appointments on next page) Lourdes Ear, Nose & Throat 1200 N. 14 th Avenue Suite 350 Pasco WA 99301 (509)545-4800 Page 1

No-Show and Cancellation Policies Our Valued Patient: As you may know, there is a shortage of ENT providers in the Tri-Cities. This shortage makes our office very busy, often with long waits to obtain a routine appointment. We want to be as efficient as possible to help you be seen in our clinic as timely as possible. Understandably, it can be frustrating when a person does not show up for an appointment. This noshow problem should be frustrating to you, too, because those are un-used appointments that you or your loved ones could use for important medical help. People who make appointments and don t keep them cause everyone else s appointment to be delayed. For this reason, our no-show policy is as follows: 1. For the first no-show within 12 months, a letter will be sent to the person explaining this policy. 2. For the second no-show, a warning letter will be sent, Informing of a potential dismissal from our practice. 3. For the third no-show, a certified letter will be sent, dismissing that person from our practice. We want to work with you to provide the best, most efficient service possible. If for some reason you are unable to keep an appointment, please provide us 24 hours notice so that we can help you to reschedule. Except in the case of emergencies, giving less than 24 hours notice is considered a noshow. Also, if you are more than 15 minutes late for your appointment you will be considered a noshow and the same policies apply. Respectfully, The Providers and Staff at Lourdes Ear, Nose & Throat 1200 N. 14 th Avenue Suite 350 Pasco WA 99301 (509)545-4800 Page 2

LOURDES EAR, NOSE & THROAT PATIENT INFORMATION SHEET Name: AKA(Maiden or Other Name) (Last) (First) (Middle) Preferred Name: Mailing Address: City: State: Zip: Preferred contact number: Home Work Cell DOB: / / (Month) (Day) (Year) SSN Email Male Female Marital status: Single Married Divorced Widowed Employer: Is this a work related injury? Yes No Primary Care Physician: Pharmacy: Employment status: Employed Unemployed Retired Retirement date Spouse Employment status: Employed Unemployed Retired Retirement date Student Status: Full time Part time N/A Ethnicity: Primary language: Interpreter needed? Yes No Provided by Have you traveled (outside of the USA) recently? Yes No If so, where? If a child with whom does the patient reside? Mother Father Both Parents Guardian* *(Guardianship Papers or verbal Parental Permission required prior to examination if parent not present) INSURANCE INFORMATION PRIMARY Insurance name: Subscriber name: DOB: Male Female Telephone number: Relationship: Self Spouse Child Other Explain other: Policy number: Group number: SECONDARY Insurance name: Subscriber name: DOB: Male Female Telephone number: Relationship: Self Spouse Child Other Explain other: Policy number: Group number: EMERGENCY CONTACT INFORMATION Name: Telephone: Relationship: Name: Telephone: Relationship: Signature: Date: Page 3

LOURDES EAR, NOSE & THROAT PATIENT MEDICAL HISTORY Name: DOB: / / Medical History: Check if Yes for any of the following: Acid reflux (GERD) Preferred Pharmacy: Current Medications: (We recommend bringing current medication bottles to your appt.) See attached list Asthma No current medications Cancer (type ) Name Dose Cleft Palate/Cleft Lip 1. / Diabetes type I type II 2. / Environmental/Seasonal Allergies 3. / Hearing Loss 4. / Heart Disease 5. / High blood pressure 6. / Migraines 7. / Obstructive Sleep Apnea Use Back of Page if Necessary Recurrent Ear Infections Medication Allergies/Reactions: Recurrent Sinus Infections None Recurrent Tonsillitis 1. / Seizure Disorder 2. / Snoring 3. / Stroke Food or Environmental Allergies/Reactions: Thyroid Disease None Tinnitus (ringing in ears) 1. / TMJ (jaw pain, locking) 2. / Other 3. / Other Have you had any surgeries? Have you recently been hospitalized? No Surgeries If so, when and for what reason? ENT surgery: Tonsillectomy yr: Ear tube(s) yr: Thyroidectomy yr: Adenoidectomy yr: Septoplasty yr: Parathyroidectomy yr: Sinus surgery yr: Tympanoplasty yr: Mastoidectomy yr: Other surgery: Page 4

LOURDES EAR, NOSE & THROAT PATIENT MEDICAL HISTORY Please check box if you have been experiencing any of the following symptoms: General: Mouth and Throat: Musculoskeletal: None None None Fever Dry Mouth Joint Pain Chills Mouth Lesion(s) Joint Stiffness General Weakness Bad Breath/Bad Taste Muscle Aches Fatigue Painful Tongue Skin: Weight Loss / Gain Sore Throat None Eyes: Lump in Throat Rashes None Difficulty Swallowing Changes in mole(s) Dry Hoarseness Growths Red Snoring Hair or nail changes Blurred Vision Cardiovascular: Neurological: Double Vision None None Itching Chest Pain Headache Excess Tearing/Watering Lightheadedness Dizziness Ears and Nose: Palpitations Seizures None Racing Heart Beat Numbness/Tingling Ear Pain Swelling of Feet/Ankles Psychiatric: Ear Discharge/Drainage Respiratory: None Loss of Hearing None Nervousness, Anxiety Sneezing Cough Depression Nasal Congestion Wheezing Memory Loss Runny Nose Short of Breath Endocrine: Sinus pressure Gastrointestinal: None Sinus pain None Heat Intolerance Nasal Discharge Heartburn Cold Intolerance Post-Nasal Drip Loss of Appetite Excessive Thirst Nosebleeds Nausea/Vomiting Hematologic and Lymphatic: Loss of Sense of Smell Genitourinary: None None Frequent Urination Blood in Urine Painful Urination Easy Bruising Easy Bleeding Enlarged Glands Page 5

Social History: LOURDES EAR, NOSE & THROAT PATIENT MEDICAL HISTORY Do you No Yes If yes please answer below Drink caffeinated beverages? # cups of coffee/day ; # sodas/energy drinks/day Drink alcohol? # drinks/day ; # drinks/week Smoke tobacco? # cigs/day ; # packs/day ; # of years Chew tobacco? # cans/day ; # cans/week ; # of years Use illicit drugs? drug(s) ; duration Are you A former smoker? # cigs/day ; # packs/day ; # of years Exposed to second hand smoke? Often exposed to loud noise? type Do you have a family history of any of the following? Family History Asthma Autoimmune Disease Cancer (type: ) Diabetes Genetic syndrome Hearing Loss Heart Disease High Blood Pressure Migraines Seasonal Allergies Sleep Apnea Stroke Thyroid Disease Other: Which Family Member(s) Signature: Guardian, if patient is under 18 years old: Relationship to Patient: Page 6

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