Tennessee Neurology Specialists Affiliated with Baptist Healthcare Group Oscar E. Mendez, M.D. Rejane Lisboa, M.D. Williamson Medical Center Tower 4323 Carothers Pkwy, Suite 303 Franklin, TN 37067 Phone: (615) 538-6045 Fax: (615) 538-6049 Nurse: Brenda Billing: Mandy: (615)383-8575 Ext. 112 Receptionists: Michelle Samantha: (615) 383-8575 Ext. 121 IMPORTANT- PLEASE READ BEFORE YOUR APPOINTMENT INSURANCE: All patients must bring their current insurance card/cards. If you have more than one insurance carrier, we will need to know which company is primary. To avoid payment problems, contact your insurance carrier prior to your visit to check on your coverage. Please be aware of any deductible or copayments amounts. Patients will be required to make payments at the time of their office visit. PHONE CALL POLICY: Nurses return phone calls after morning clinic hours. Generally, calls are returned between 1:30 PM and 3:30 PM. Phone calls received after 3PM will be returned in the next business day. Calls are returned based on their urgency and order received. Due to the volume of daily patient calls, please leave only one message. Multiple messages will only slow the process of returning calls. Persistent calls could result in a charge to the patient of $25.00. Some doctors will return phone calls at night and will use a restricted number. IF YOU HAVE A BLOCK ON RESTRICTED NUMBERS, YOU MIGHT NOT GET A CALL. PRESCRIPTION REFILLS: You may have your pharmacy fax our office a refill request at (615) 538-6049. Generally, we are able to fax the refill within the same business day. Call your pharmacy regarding the status of your refill. Prescriptions needing PRIOR APPROVAL (PA) by an insurance company can take up to 72 hours to obtain. Your insurance company will notify the pharmacy of the approval. Routine refills should be requested during the week and no medications will be refilled during weekends or holidays. If you need a written prescription, call the nurse with the medication, dose, and quantity. We will mail the prescription to you. Mail order prescriptions will be mailed to you as well. TEST SCHEDULING/SPECIALIST REFERRAL: Our front office staff will schedule tests/referrals at the time of your office appointment. If you are unable to keep the scheduled appointment, you will need to contact the facility where your appointment has been made to reschedule. If you do not contact the facility, it is their privilege not to reschedule you. If a test appointment is cancelled and not re-scheduled at the time of cancellation, a new appointment must be made through our office. EMERGENCY PHONE CALLS DURING OFFICE HOURS: Dial O for the front desk and ask for assistance. EMERGENCIES AFTER HOURS: We have a 24 hour answering service. Call the office number and dial 0, the operator will take your message and page the on-call physician. Please do not call the on-call physician to refill routine prescriptions on the weekend. The on-call physician does not have access to your medical records.
Patient Name Date Date of Birth 1. Please describe your medical problem: 2. Please list and describe your medical illnesses: a. If you have been treated for any of the medical problems below, please circle and indicate the approximate date: b. High Blood Pressure e. Stroke c. Heart Disease f. Epilepsy d. Cancer g. Mental Illness e. Diabetes Mellitus (sugar diabetes) h. Other 3. Have you had any operations? Please list and provide dates: 4. Family History: a. Father s age: Illnesses Cause of Death b. Mother s age Illnesses Cause of Death c. Brothers/Sisters: (Attach a list or continue on the back if needed) d. Age Illnesses Cause of Death e. Age Illnesses Cause of Death 5. Has anyone in your immediate family had: a. High Blood Pressure Yes No Strokes Yes No b. Heart Disease Yes No Mental Illness Yes No c. Cancer Yes No Epilepsy Yes No d. Diabetes Yes No Migraine Yes No 6. Weight History: Present Weight: LBS. Usual Weight LBS Height ft in 7. Have you had any changes in your weight in the last year? Yes/No Amount of weight loss/gain: 8. Have you ever experienced physical/emotional/sexual abuse? Yes/NO If yes, which? 9. Have you fallen in the last year? Yes/No Number of times 10. Did you injure yourself during the fall(s)? Yes/No 11. Habit History (Please Circle): a. Smoking: Non-Smoker Current Smoker Former Smoker b. Alcohol: Yes/No #oz per day Number of Yrs Date Started c. Coffee/Caffeine: Yes/No Cups per day 12. Are you allergic to any medicines? Yes/No please list if yes: ** PLEASE USE SPACE BELOW TO LIST ALL CURRENT MEDICATIONS** Name of Medication Dosage Frequency Please mark YES or NO for the symptoms below.
General YES NO Lethargy/weakness Weight loss Dizzy Spells Fainting spells/unconsciousness Chills/night sweats/fever Sleeps Difficulties EYES: Glasses/contacts Laser surgery (date ) Double Vision Eye Pain Eye sight worsening EARS/NOSE/THROAT Hearing Loss/Deafness Noise in Ears Congestion/sneezing Sinus Trouble/hay fever Nose Bleeds Sore Throat HEART: Chest Pain Heart Attack Heart Murmur Swollen feet ankles KIDNEY/BLADDER/PROSTATE: YES NO Frequent night or day voiding Burning on urination Pus or blood in the urine Difficulty starting urine Dribbling with coughing/sneezing Other kidney problems Sexual Difficulties Prostate Disease NEUROLOGY: Difficulty making decisions Memory Problems Numbness or tingling Weakness Aching muscles/joints Frequent Headaches PSYCHIATRY: Cry often/depressed/feel sad Considered suicide Loss of interest in eating Anxiety/tension Loss of energy HEMATOLOGY/IMMUNOLOGY: Bleed/bruise easily Anemia/low blood Blood Disease Enlarged glands/nodes LUNG: Wheezing/coughing spells Coughing- up phlegm Shortness of Breath Chest Pain Coughing-up blood ENDOCRINE: Tired Weak Thirsty Swelling Skin Changes STOMACH: Difficulty Swallowing Ulcers Heart burn or indigestion Stomach pain Vomiting blood Constipation Recent change in bowel habits Loose bowels/diarrhea Date of last colonoscopy SKIN: BREAST/MENSTRUAL: Lumps in breast Last menstrual period Date: Menstrual irregularity Skin Rash Sores Skin cancer ADVANCE CARE PLAN Living will Emergency contact Reviewed by M.D. Date PATIENT INFORMATION PATIENT INFORMATION SHEET
FULL NAME: DATE OF BIRTH: ADDRESS: PHONE (HOME): CITY: STATE: ZIP: SOC SEC#: EMAIL ADDRESS: CELL PHONE: NAME OF EMPLOYER: PHONE: SPOUSE S NAME: WORK PHONE: Circle One) SEX: Male Female Transgender MARITAL STATUS: Married Single Divorced Widowed ETHNICITY: Caucasian African-American Hispanic Other LANGUAGE: English Spanish Other PERSON LEGALLY RESPONSIBLE FOR BILL FULL NAME: ADDRESS: CITY: STATE: ZIP: PHONE (HOME): BUSINESS: RELATIONSHIP: *PHARMACY NAME: PHONE: ADDRESS: FAX: INSURANCE INFORMATION- LIST ALL INSURANCE INFORMATION AS ACCURATELY AS POSSIBLE 1) PRIMARY CARRIER: NAME OF EMPLOYER: POLICY HOLDER NAME: DATE OF BIRTH: SS# OF POLICY HOLDER: RELATIONSHIP: 2) SECONDARY CARRIER: NAME OF EMPLOYER: POLICY HOLDER NAME: DATE OF BIRTH: SS# OF POLICY HOLDER: RELATIONSHIP: FRIEND OR RELATIVE NOT LIVING WITH YOU TO BE CONTACTED IN AN EMERGENCY NAME: PHONE (HOME): RELATIONSHIP: ADDRESS: CITY: STATE: ZIP: REFERRING PHYSICIAN AND PRIMARY CARE PHYSICIAN REFERRING MD: PRIMARY MD: OFFICE #: OFFICE #: ****SIGNATURE OF PATIENT**** DATE TENNESSEE NEUROLOGY SPECIALISTS
Michael J. Kaminski, M.D. Robert J. Fallis, M.D. Oscar E. Mendez, M.D. E. Frank Lafranchise, M.D. Rejane C. Lisboa, M.D. Roxanne M. Valentino, M.D. Ikuko Laccheo, M.D. READ THIS CHECKLIST CAREFULLY The enclosed information regards your appointment for neurological evaluation at Tennessee Neurology Specialists. In order for us to provide the best medical care, please complete the following items before your visit. 1. Completely answer the questions on the enclosed forms. 2. Please bring a detailed list of all current medications with dosages. If you do not have a list, bring your medication bottles with you. 3. Verify that we have received your medical records from your referring physician. You may also bring these on the day of the appointment. You may have your medical records faxed to us at 978-701-6019. 4. If you have had any MRI or CT scans in the last six months bring the actual films or a CD to your visit. 5. Determine if your insurance company requires prior authorization for your specialist visit. These referrals can require 48 hours to process. If you have questions about your insurance, do not hesitate to call. 6. Should you need to cancel or reschedule an appointment, please contact our office 24 hours prior to your scheduled visit. **NOTE** If you have previously seen another neurologist, notify our office prior to your appointment. Contact our office with any questions. *************PLEASE SEE BOTH SIDES************