NEW PATIENT - ADULT (Please print) PATIENT NAME: DATE: Last Name, First Name MI ADDRESS: (street) APT #: (city/state) ZIP: Home Phone: Cell Phone: Email: Date of Birth: Age: SS # Martial Status: DRIVER S LICENSE NO. STATE: GENDER: PARENT/GUARDIAN IF MINOR: EMPLOYER S NAME: OCCUPATION: EMPLOYER S ADDRESS: PHONE: SPOUSE S NAME: Date of Birth: SS# SPOUSE S EMPLOYER: OCCUPATION: EMPLOYER S ADDRESS: PHONE: PRIMARY CARE PHYSICIAN: PHONE: ARE YOU A PREVIOUS PATIENT? YES NO HOW LONG AGO? *INSURANCE INFORMATION* PRIMARY INSURANCE CO. PHONE: ADDRESS (street, city, state, zip): INSURED S NAME: SUBSCRIBER # GROUP # MEDICARE # SECONDARY INSURANCE CO. PHONE: ADDRESS (street, city, state, zip): INSURED S NAME: SUBSCRIBER # GROUP # MEDICARE # ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize direct payment of surgical/medical benefits to Dr. Shelley Jaquish and Dr. Timothy Dunlevy for services rendered by them in person or under their supervision. I understand that I am financially responsible for any balance not covered by my insurance. AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I HEREBY AUTHORIZE Dr. Shelley Jaquish and Dr. Timothy Dunlevy to release any medical or incidental information that may be necessary for either medical care or in the processing application for financial benefit. MEDICARE*MEDICAID: I certify that the information given by me in applying for payment is correct. I authorize release of all records request. I request that payment of authorized benefits be made on my behalf. FINANCIAL RESPONSIBILITY: I assume financial responsibility for my office visit if I do not obtain the proper referrals from my primary care physician for my office visit. A photocopy of these assignments shall be valid as original. PATIENT NAME: (please print) PARENT OR GUARDIAN: (please print) SIGNATURE: DATE: Pasadena ENT & Allergy / Audiology New Patient Adult (from website) Page 1 of 6
ADULT MEDICAL QUESTIONNAIRE NEW PATIENT Date of Visit PATIENT NAME: AGE: Date of Birth: PRIMARY CARE PHYSICIAN: Physician s Phone: WHO REFERRED YOU? (DOCTOR, FRIEND, N/A): CHIEF COMPLAINT/REASON FOR VISIT: PAST MEDICAL HISTORY Circle any of the following you currently have or have had in the past: heart attack asthma diabetes irregular heart beat COPD/emphysema Cancer: type heart disease chronic bronchitis ulcers hypertension kidney disease migraine headaches vascular disease thyroid disease allergic rhinitis/hay fever blood clots or bleeding problems sleep apnea other: ALLERGIES: (List drug allergies and reactions) PAST SURGICAL HISTORY: (Please list ALL surgeries and dates of surgeries) CURRENT MEDICATIONS: (including vitamins, herbals, over the counter medicines) FAMILY HISTORY Please list any ILLNESSES in your immediate family: Mother: Father: Sisters: Brother: Have you or a relative ever had a problem with anesthesia? YES NO Excessive bleeding? YES NO Pasadena ENT & Allergy / Audiology New Patient Adult (from website) Page 2 of 6
SOCIAL HISTORY: Occupation Do you drink? YES NO Amount per week Do you smoke? YES NO Number of packs per day When did you quit? Do you take aspirin? YES NO How much? Do you have a history of noise exposure? YES NO Explain: Do you wear hearing aids? YES NO Please circle which ear: RIGHT LEFT Both Do you drink caffeine? YES NO Number of caffeinated drinks per day: Do you have pets at home? YES NO What type? REVIEW OF SYSTEMS: Circle only the symptoms you currently have now or have had recently. GENERAL: excessive daytime sleepiness joint pain muscle aches weakness fatigue malaise chills night sweats SKIN: color changes rashes itching sores dryness HEAD: headaches: location severity 1-10 nausea/vomiting light sensitivity sound sensitivity EYES: double vision watery eyes dry eyes blurred vision redness itching burning EARS: hearing loss ringing discharge earache itching loss of balance dizziness spins NOSE: decreased smell bleeding pain discharge obstruction runny nose postnasal drip deviated septum sinus congestion nasal congestion snoring MOUTH: bleeding gums sores dentures pain bad breath loss of taste canker sores THROAT: sore throat hoarseness hard to swallow recurrent infections throat clearing lump in throat postnasal drip NECK: pain lumps enlarged lymph nodes LUNGS: dry cough phlegm cough blood shortness of breath wheezing pain in lungs chest congestion HEART: fainting palpitations rapid heartbeat swollen extremities chest pains GASTROINTESTINAL: food allergy: heartburn abdominal pain nausea vomiting indigestion constipation diarrhea NEUROLOGICAL: slurred speech seizures vertigo loss of facial expression weakness disequilibrium dizziness tingling/burning/numbness (location) For Office Use Only: HT: WT: TEMP: HR: BP: RESP: Pasadena ENT & Allergy / Audiology New Patient Adult (from website) Page 3 of 6
CONSENT TO USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION Your protected health information will be used by Pasadena ENT & Allergy, or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice. You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent. You may request a restriction on the use or disclosure of your protected health information. Pasadena ENT & Allergy may or may not agree to restrict the use or disclosure of your protected health information. If Pasadena ENT & Allergy agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. REVOCATION OF CONSENT You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. Pasadena ENT & Allergy reserves the right to modify the privacy practices outlined in the notice. I have reviewed this consent form and give my permission to Pasadena ENT & Allergy to use and disclose my health information in accordance with it. Name of Patient (Print or Type) Signature of Patient Signature of Patient Representative Relationship of Patient Representative to Patient Pasadena ENT & Allergy / Audiology New Patient Adult (from website) Page 4 of 6
Our goal at Pasadena ENT and Allergy is to provide you with the utmost in quality health service, with a focus on your care, cost and convenience. In order to properly assess your medical status, your physician may need to perform a service your insurance company may consider a surgical procedure. This may subject you to an additional cost on top of your office co-payment. These include procedures such as: Nasal or Laryngeal (throat) endoscopy Cerumen (ear wax) removal Biopsies Myringotomy (ear tubes) Treatment of nose bleeds Any type of treatment that may include a needle or surgical instrument Unfortunately, we have no way of knowing ahead of time if your insurance company will: process this procedure as a surgery access you an additional co-pay require an additional share of cost from you (called co-insurance) apply the allowed amount to your deductible, if your deductible has not been met. You have the option of checking with your insurance company and returning for another appointment. Should you choose to return for an additional appointment, you will be subject to an additional office co-payment. I hereby authorize direct payment of surgical/medical benefits to Dr. Shelley Jaquish and Dr. Timothy Dunlevy for services rendered by them in person or under their supervision. I understand that I am financially responsible for any balance not covered by my insurance. Signature of Patient: Date: Parent / Guardian: Date: Pasadena ENT & Allergy / Audiology New Patient Adult (from website) Page 5 of 6
CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION 1. Permission to Use and Disclose My Health Information. By signing this form, I give PASADENA ENT & ALLERGY AUDIOLOGY DEPARTMENT, permission to use and/or disclose my health information to carry out diagnostic testing, treatment, and payment. 2. Right to Refuse. I have the right not to sign this consent. If I refuse to sign this consent, PASADENA ENT & ALLERGY AUDIOLOGY DEPARTMENT will not provide me with diagnostic testing or treatment until I consent. However, treatment required by law, such as emergency care, can be provided to me whether or not I sign this consent. 3. Right to Review Notice of Privacy Practices. PASADENA ENT & ALLERGY will provide me with a copy of their Notice of Privacy Practices which describes how PASADENA ENT & ALLERGY may use and disclose my health information, upon my request. I have the right to review this notice before signing this consent. 4. Changes to the Privacy Notice. PASADENA ENT & ALLERGY may change the Notice of Privacy Practices as needed. I may obtain a current copy of PASADENA ENT & ALLERGY S Notice of Privacy Practices by contacting PASADENA ENT & ALLERGY. 5. Right to Request Restrictions on Use/Disclosure. I have the right to request that PASADENA ENT & ALLERGY restrict how they use and/or disclose my protected health information for the purpose of providing diagnostic testing, treatment, obtaining payment for services, and/or conducting healthcare operations. PASADENA ENT & ALLERGY is not required to agree to any restriction I request. If PASADENA ENT & ALLERGY does decide to agree to my request, they must restrict their use and/or disclosure of my health information the way I asked. Because of the number, complexity, and nature of the services they deliver, PASADENA ENT & ALLERGY will notify me of their decision to accept my restrictions. Restrictions: 6. Right to withdraw consent. I have the right to withdraw this consent at any time. I must do this in writing. If I want to withdraw this consent, I can contact PASADENA ENT & ALLERGY at 6827 FIRST AVENUE SOUTH, SUITE 100, ST. PETERSBURG, FLORIDA 33707. Note that my withdrawal of this consent will not be effective for uses and/or disclosures that have already been made based on my prior consent. If I withdraw this consent, then PASADENA ENT & ALLERGY, by law, is unable to provide to me further treatment or follow-up, other than required emergency services. 7. Effective Period. This consent is good until I withdraw it in writing. 8. References to I or me. References to I or me in this consent include the individual for whom the signing party is authorized to sign. If I am signing this consent on behalf of another person, it is because I am the legal guardian, parent, or agent under an active Power of Attorney for Health Care, and I am legally authorized to sign this Consent on behalf of the individual. Pasadena ENT & Allergy Audiology Department may contact me via: (check all that apply) Telephone Email Information may be disclosed to the following individuals: (check all that apply) Spouse (Name): Children (Name): Other (Name): Message or Appointment Reminders: We may leave a message at your home using doctor s/practice name. Yes No We may leave a message at your work using doctor s/practice name. Yes No Patient Signature: Date: Pasadena ENT & Allergy / Audiology New Patient Adult (from website) Page 6 of 6