Family Medicine Division. Nyree Bryant DO George R. Davis DO
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1 Family Medicine Division Nyree Bryant DO George R. Davis DO 11/12/17 Dear New Patient, Welcome to Florida Medical Clinic! We are happy that you have made our office your choice for your medical care needs. In order for us to provide you with excellent service and quality care, we ask that you take a few moments to read over some important information. If you are a new patient that has been assigned to our office, our physicians recommend that you make an appointment with our office as soon as possible but no later than 7 days for a new patient visit. Please contact the office during regular business hours at (813) to schedule an appointment. We are located at N. 56 th Street, Tampa, FL Please do not hesitate to contact our office for directions. We provide equal access to all patients accepted into this practice. We are pleased to announce a new initiative in the office called Patient-Centered Medical Home (PCMH) -- a new way of managing your health care. PCMH is a model of care designed to improve the coordination of your health care with an emphasis on your all-around well-being. This means that the Physician and your care team will: Care for you based on your own needs, health profile, and history. Explain the choice you have for care and help you decide which on is best for you. Guide you through the health care system so that we work as a team if you ever need more care from a specialist. Help you try to improve your health by talking with you about wellness, prevention, and followup care. We offer the following ways to contact us to get the care you need: 1. Contact the office directly during regular business hours at (813) Our office is open Monday Friday 8:00 AM 12:00 PM and 1:00-5:00 PM, and 7:00 AM- 5 PM on Wednesdays During Business Hours: Urgent messages left before 4 PM will be answered within 2 hours. Routine or non urgent messages will be answered by the end of the business day. 2. Via Internet- using the patient portal with secure messaging. 3. AFTER HOURS CARE: To speak to our physicians or require after hours care, please call (813) and an operator will contact the physician to coordinate your care. Our physicians are available to you ANYTIME during the day or evening hours if you have an urgent need. Please call 911 in the event of an emergency. PRESCRIPTION REFILLS: We ask that medication refill requests be done 48 hours in advance. Our office offers several ways to request medication refills: 1. We prefer you contact your retail or mail order pharmacy directly, they will send us a refill request. 2. Contact the office directly during regular business hours at (813) Contact the office through our patient portal utilizing secure messaging. HOSPITALS: Florida Hospitals Tampa and Wesley Chapel are the Hospitals in our area. Florida Medical Clinic has a team of hospital medicine physicians that will coordinate your care while you are the hospital. Upon arrival to any hospital, please inform the hospital staff who your primary care physician is and that you are a patient of Florida Medical Clinic.
2 REFERRALS: Your insurance plan may require referrals for most services provided outside the Primary Care Physician s office. Our physicians utilize the services of a preferred network of specialist and facilities. It is very important to make sure you have a referral for any service not provided by your Primary Care Physician. These services include, but are not limited to: Office visits to a specialist Any diagnostic studies such as MRI, X-ray, etc. Therapy services Home health care services and items such as walkers and wheelchairs If you are not sure if the service you need requires a referral, please contact our office or your insurance carrier for verification. OUT OF AREA CARE: When traveling outside the service area it is very important to contact your Primary Care Provider prior to receiving medical care, unless the care is emergent or urgent. Here are some helpful hints while outside the service area: Prior to leaving town, make an appointment with your Primary Care Provider for a routine checkup, refill medications, and to answer any questions you may have about your medical care while out of town. Contact your primary Care Provider prior to receiving medical care. Our physicians can be reached after hours and on the weekends by calling the office number and leaving a message with the answering service to have a provider return your call. When emergencies happen and hospitalization is necessary the hospital takes care of contacting the insurance company for authorization. If possible, while in the hospital, if you or a family member could contact the office to let your physicians know right away, you have been admitted this will help facilitate coordination of care. If this is not possible, once you are released from the hospital it's your responsibility to contact your Primary Care Physician for any further authorizations. Any care not provided as inpatient admission to the hospital will require a referral in order to be covered. When labs need to be drawn out of state, it is very important to use a lab that is contracted with your insurance plan. If you are unable to locate a lab in your area please contact your insurance plan. NO-SHOW POLICY: No-Show definition: Any scheduled office appointment in which a patient fails to maintain. Patient is considered a No-Show when: The patient is more than 15 minutes late for his/her appointment. Patient does not contact the office to cancel the appointment prior to the appointment time. Patient-centered care won t work without your help. We want you to be an active part of your own healthcare. Here are some ways you can do that. Learn about your health condition and what you can do to stay as healthy as possible. Follow the care plan that you and your medical team create together. Bring any questions you have to each visit. Also, bring all medication bottles including vitamins and any over the counter medications with you on each visit. Ask us to explain if you don t understand something Tell us if you get care from other health professions, so we can work with them for the best care possible. Talk with us about your experience getting care from us, so we can keep making it better.
3 Again, we would like to welcome you to our practice and look forward to providing you with excellent care and service. Sincerely, Your Healthcare Team
4 FAMILY HISTORY FORM Patient Name: Date: Please only check if your family member HAS or HAD the listed chronic condition: Condition: Mother Father Brother Sister Other Hardening of Arteries Arthritis Asthma Heart Disease Cancer Cataract Color Blind Depression Diabetes Mellitus Eczema: Skin Condition Epilepsy Glaucoma High Blood Pressure High Cholesterol Central Loss of Vision Mental Illness Migraine Headache Osteoporosis Kidney Disease Retinal Detachment Stroke Thyroid Disease Please Specify Other:
5 PATIENT HISTORY FORM Patient Name: Patient DOB: Today s Date: What are you being seen for today? Please Print your current medications and dosage (include prescribed and over counter, vitamins and supplements): Are you currently being treated for any of the following? (Please circle all that apply) Diabetes Thyroid Disease High Blood Pressure High Cholesterol Heart Disease Asthma Cancer Osteoporosis Kidney Disease Epilepsy Stroke Arthritis Anemia Bleeds Easily Tuberculosis Headaches Hepatitis HIV Hayfever/Allergies Depression/Anxiety Other: Are you currently seeing any other physicians? If yes, please list: Allergies (Please list your allergies below and include the type of reaction): Medications&Reaction: Food: Latex/Other: Surgeries/Accidents/Hospitalizations:(please list and include dates) Family History Age Alive/Deceased Medical Issues/Diseases If deceased, cause of death Father Mother Grandparents/Maternal Grandparents/Paternal Siblings Brothers # Siblings Sisters# Spouse Children # of Children Other: Social History Employer & Occupation: Occupational Exposures []Fumes []Dust []Solvents []airborne particles []noise Marital Status: []Single []Married []Separated []Divorced [] Widowed Alcohol: []Never []Rarely []Moderate []Daily Drinks/week/day Type? Tobacco: []Never [] Rarely []Frequently Packs/day []Previously but quit when? Caffeine: []Never []Rarely []Frequently Amt/daily Type: Use of drugs: []Never []Rarely []Previously, but quit, when? Type?
6 Social History (con t) Patient Name: Patient DOB: Do you exercise? []No []Yes If Yes, How often and what type: Are you sexually active? []No []Yes Do you travel outside USA? []No []Yes If Yes, where: Smoke Detector in your home? []No []Yes Religion (optional): Do you have a Living Will []No []Yes Do you have an Advanced Directive []No []Yes Do you have any pets? []No []Yes If Yes, please list type and # Review of Systems Please indicate any personal & current symptoms below Constitutional Systems Comments Recent Weight Change Fever Chills Sleep Disorder Other: Eyes Eye disease/cataracts Wear glasses/contacts Blurred/double vision Glaucoma Other: Ear/Nose/Throat/Mouth Hearing changes Sore throat Chronic sinus problems Nose bleeds Other: Cardiovascular Chest Pain Irregular heartbeat Swelling in ankles Murmur Other: Endocrine Excessive thirst Too hot/cold Tired/sluggish Other: Hematologic/Lymphatic Swollen glands Blood clotting problem Bruising Other: Allergic/Immunologic Hay Fever Drug Allergies Food Animal Other: Sexual History Change in sex drive Sexual performance satisfactory Sexual Trauma Other concerns: Gastrointestinal Abdominal Pain Nausea/vomiting Indigestion/Heartburn Other: Respiratory Wheezing Frequent Cough Shortness of Breath Other: Neurological Tremors Dizzy spells numbness/tingling Frequent/headaches Seizures Other: Integumentary (skin) Rash Lumps/bumps Moles/skin tags Other: Comments Musculoskeletal Bone pain Muscle pain Joint pain Other: Genitourinary Change in urine stream Nocturia (getting up at night) Urinary frequency >8x/day Other: Psychological Are you generally happy? Do you feel depressed? Do you feel anxious? Do you feel safe at home Other concerns: Last Exam or Lab tests Please enter date (mo/yr) Dental: Eye: Pelvic: Pap Smear: Prostate: PSA: Mammogram: Colonoscopy: Cholesterol: Stool Tested: Are you here today to review any of the above issues? If yes please list them: *Any non-urgent issues marked above that are not address today should be addressed in a follow up visit or physical. Your physician will instruct you if a follow up is necessary. For Office Use Only: Dr/PA/NP sig: Date:
7 FLORIDA MEDICAL CLINIC Family Practice Temple Terrace Patient Responsibility for Follow Up A note to our valued patients, We view your healthcare as a shared responsibility. We will always endeavor to provide you with the best health care possible. This may mean we need to order diagnostic tests and/or refer you to other health care providers. As such, we ask you to partner with us and accept the following responsibilities. Patient Name: (Initial) When any tests or consultations are ordered for you, we rely on you to accept responsibility to schedule any needed appointments in a timely manner. Feel free to ask us to help you with the scheduling process. If you haven t heard from someone about the results within two weeks of the test being done, please contact us to be sure the information is available and that you know what the results are and what needs to be done next. If it is unclear to you what the next step is after a consultation or test, we will rely on you to ask about it or any other questions you may have. Sometimes, no news is not good news, just no news. (Initial) If follow up is ordered, such as repeat or additional testing, medication or other treatment changes, visits, etc, we will rely on you to accept full responsibility for following up on this, including any consequences of not following up. Reminders will not be given. If you have any questions about the necessity of, or reason for, the test, consultation or other follow up, we will rely on you to ask those questions. I understand the above and agree to this. Signature Date Witnessed Date George R. Davis, DO Nyree D. Bryant, DO North 56 th Street Tampa, Florida (813) (813)
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Family Medicine Division. Nyree Bryant DO George R. Davis DO
Family Medicine Division Nyree Bryant DO George R. Davis DO 11/12/17 Dear New Patient, Welcome to Florida Medical Clinic! We are happy that you have made our office your choice for your medical care needs.
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(Please Print) PATIENT INFORMATION. Sex: Male Female Home phone no: ( ) City: State: Zip: Cell phone no: ( ) Occupation: Employer: Work phone no: ( )
(Please Print) Today s date: Primary Care Physician: PATIENT INFORMATION First name: Middle: Last: Former name: Marital Status: Single Married Divorced Widowed Street address: Birthdate: SSN: Email Address:
Burton M. Sundin, M.D. / Reps B. Sundin, M.D. Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: address:
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M or F Patient s Date of Birth Patient s Social Security Number Sex. Secondary Address: (if have, Northern) Street City State Zip Code
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Social Security Number: Employment Status: Employed Unemployed Address: Student Retired
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