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lefttop7700 Cat Hollow Dr Ste 205Round Rock TX 78681Phone 512 218 4900Your appt with ___Dr Anderson___Dr Matsubara Date_________________ Time _________ How to Get the Most Out of Your Office Visit1) When you call to schedule your appointment, please tell the receptionist what you need to be seen for (i.e.physical for work or school, annual physical, fever, injury, chest pain, follow up, etc). If you have a medicalemergency, tell the receptionist right away! Also tell us if you have several medical problems for which you wantto be seen, so we can schedule your appointment appropriately. Typically one visit allows time to address oneproblem, though this depends on the complexity of the problem.2) If you are requesting a full annual physical, or a pap/ well woman exam, clearly tell the receptionist when youcall for an appointment. We schedule more time for physicals and pap. With physicals and preventive exams,such as pap/well women exams, well child exams, etc., we use the entire time to do a thorough exam anddiscuss preventive issues. If there are separate problems or concerns, we ask that a separate problem visit be scheduled.3) Record the date and time of your appointment on your calendar. If a time conflict arises and you cannot keepyour appointment or if you will be arriving late, please call our office at 218-4900, 24 hours in advance.4) New Patients are requested to arrive 30 minutes early to complete the necessary paperwork. We must enteryour demographics into our computer system before a medical provider can see you.5) When you check in at the front desk, please let us know if there are any changes in your address, phone,insurance, etc. Reporting these changes NOW will help to prevent insurance billing problems later for you. Tellthe receptionist TODAY.6) Once you are in the exam room with our medical assistant, please also let him/her know the reason for yourvisit and if you had any lab work or other tests done before you came in.7) If you have several medical problems, it may not be possible to take care of all of them during oneappointment. Please tell the provider the 2-3 problems that most disturb you, and we will decide which one(s) toaddress and schedule an additional appointment for the rest. Don’t wait until you are ready to leave the room tobring up another significant problem.8) Bring all your medications with you to your appointment. Include over the counter products, vitamins andherbal remedies. Tell us about any allergies or past drug reactions. It is very important that we know exactly whatmedications you are taking so we do not prescribe something which will interact with your other medications.9) Be knowledgeable about your medical history. Take the time to write out your family’s medical history. Bringthis with you to your medical appointment.10) Be knowledgeable about your insurance benefits and what is covered under your policy. Explain to our staffany concerns you have about the coverage of certain tests prior to the actual test. Know if your insurance requiresprior approval before tests, etc. Call your insurance company ahead of your visit especially for well child visits.WELCOME TO OUR OFFICE! lefttopPatient name: ____________________ (F)________________ (L)____________ (M). Date____________Home address: _____________________________________________________________________________________City _____________________________________________________ State ______________________ Zip ___________Telephone H(______) ____________________ C(________) ___________________ W(_______) ___________________Email address___________________________________________ May we send information here? Y NOccupation: _____________________________ SSN# _______________________DOB_______________ Age _______Employer: ____________________________________________________ Zip_______________ Years there _________Employer’s address: ______________________________________________City_________________ State___________** RACE __________________________ ETHNICITY____________________ LANGUAGE ________________________Name of spouse: _______________________________________ SSN# ___________________ DOB________________Occupation ______________________________ Employer _____________________________ Years there ___________Employer’s address ________________________________________________________City _______________________Employer’s telephone ________________________________________ State ________________________Zip _________Pharmacy name & Location __________________________________________ Phone ___________________________In case of emergency, contact _______________________________________ Relationship________________________Telephone H (_____) _______________________ C (_______) ___________________ W (______)___________________May we contact you at work? Y NDo you wish correspondence to be confidential? Y NDo you wish phone calls to be confidential? Y NComplete this section only if someone other than the patient is financially responsible.Responsible party: ________________________________ Relationship to patient ________________________Home address ________________________________________SSN___________________ DOB___________City _____________________________________________State ____________________ Zip______________Telephone H (_____) _________________C (______)___________________W (______)__________________Occupation __________________________ Employer _______________________________ Years there ____Employer’s address __________________________________ City _______________ State _____ Zip_______Primary InsuranceInsurance name______________________________ Policy ID #______________________ Group #__________________Address _______________________________________City ______________________State_________ Zip ___________Insured’s name ______________________________________ DOB ___________________ SSN____________________Secondary InsuranceInsurance name______________________________ Policy ID #______________________ Group #__________________Address ______________________________________City _______________________State_________ Zip ___________Insured’s name ______________________________________ DOB ___________________ SSN ____________________Our office will file insurance for all reimbursable services, to both your primary and secondary insurance carriers. Pleaseremember that you are responsible for all deductible, copay, and non-covered service amounts. Additionally, please bereminded that you agree to notify us of any change in insurance before any services are provided. See our complete financialpolicy for details. An additional fee of $25.00 will be added if your account is sent to collections.Signature of patient or responsible party ____________________________________________Date __________________I authorize the release of any medical information necessary to process my claim.Signed________________________________ Print name ________________________________Date________________I authorize payment of medical and surgical benefits to Sundance Family Health Center.Signed _________________________________Print name _______________________________Date________________lefttopMEDICAL HISTORYFull legal name _______________________________________ Date of birth: _________________ DATE: ____________Circle above or write here name you prefer to be called: ______________________ Circle: Male or FemaleCurrent & Past Medical Problems Date of Onset (Doctor’s notes:) Surgeries DateHeart disease Yes No__________________ _______________________ ________________________ ___________Stroke Yes No__________________ _______________________ _______________________ ___________High blood pressure Yes No __________________ _______________________ ________________________ ____________High cholesterol Yes No __________________ _______________________ ________________________ ____________Diabetes Yes No __________________ _______________________Asthma or COPD Yes No __________________ _______________________Cancer of ______________ Yes No __________________ _______________________Thyroid problems Yes No __________________ _______________________Depression Yes No__________________ _______________________HIV positive Yes No __________________ _______________________OTHER: ___________________________________ __________________ ____________________________________________________________________ __________________ _____________________________________________________________________ __________________ ________________________Current Medications (include over‐the‐counter, herbs/supplements, prescription)Name Strength (mg etc.) Times/day Name Strength Times/day1.___________________________________ ______________________ ________________ 4.____________________________ __________________ ______________2.___________________________________ ______________________ ________________ 5.____________________________ ___________________ _____________3.___________________________________ ______________________ ________________ 6.____________________________ __________________ ______________Do you have any drug allergies? Yes No (If yes, list:) Any other allergies (latex, food, environmental:)Medication Type of reaction Approx. date Substance Type of reaction Approx. date___________________________ _____________________ ____________________ _______________________ ____________________ ________________________________________________ ____________________ _____________________ _______________________ ____________________ _____________________Occupation: _____________________________________ Marital status: _______________ If married, spouse’s name: __________________________Do you exercise regularly? Yes No What type? _________________________________________ How often? _________________________________Have you ever smoked? Yes No Currently smoke? Yes No _________packs/day For how long? ____________ Quit when? ___________Do you use illicit drugs? Yes No In the past? Yes No What type? _____________________________________________________________________Do you drink alcohol? Yes No What type/how often/how much? ____________________________________________________________________Do you have risk factors for HIV infection? Yes No Explain: __________________________________________________________________________Are you currently experiencing unusual stress? Yes No Explain: _____________________________________________________________________Are there any environmental risks in your job or home? Yes No Explain: ___________________________________________________________Please list most recent dates:Complete physical exam ___________________________ Chest X‐ray ________________ Tetanus shot (circle: Td or TdaP) _________________Cholesterol test _____________________________________ EKG ________________________ Flu shot ______________________________________________Eye exam ____________________________________________ Colonoscopy ______________ Pneumonia shot (Pneumovax) ____________________WOMEN:Have you gone through menopause? Yes No If yes, what age? ____________ MEN:Date last period began: _______________ Are your periods regular? Yes No Date of last PSA: _________________Date of last Pap smear: __________________ Was the result normal? Yes No Rectal/prostate exam: __________Have you ever had an abnormal Pap smear? Yes NoDate of last mammogram ____________________ Last breast exam by doctor ________________Number of pregnancies ___________ Number of live births _________ Miscarriages __________FAMILY HISTORY Have family members had any of the following diseases? Please check.Cancer (list type) Diabetes Heart Disease + Age of onset High blood pressure Stroke Thyroid disease AlcoholismFather ______________ ______________ _________________ __________ _______________________________ __________________ _________________Mother ______________ ______________ __________________ ___________ ____________________ ___________ __________________ _________________Siblings ______________ ______________ __________________ ___________ ____________________ ___________ ___________________ _________________Children_____________ _______________ _________________ ____________ ____________________ ___________ __________________ _________________If your parents are deceased, what was the cause of death? Father: ___________________ Mother: ____________________lefttopSUNDANCE FAMILY HEALTH CENTERREVIEW OF SYSTEMSNAME: _____________________________________________ DOB: _______________________ DATE _______________CURRENT OR RECENT SYMPTOMS PLEASE CHECK ALL THAT APPLY. IF NONE APPLY, CHECK HERE ________GENERAL CARDIOVASCULAR HEMATOLOGY__ WEIGHT LOSS __CHEST PAIN __UNUSUAL BRUISING__WEIGHT GAIN __CHEST PRESSURE __UNUSUAL BLEEGING__ LOSS OF APPETITE __ANKLE SWELLING__DECREASED ACTIVITY CAPACITY __SHORTNESS OF BREATH GASTROINTESTINAL__ FEVER OR CHILLS WHEN LYING DOWN __ACID REFLUX/ HEARTBURN__SWEATS __HIGH OR LOW BLOOD PRESSURE __ABDOMINAL PAIN__FATIGUE __ IRREGULAR HEART RATE __BLACK OR BLOODY STOOLS__ LEG PAIN WITH EXERCISE __NAUSEA/VOMITINGNEUROLOGIC __HEART PALPATIONS __DIARRHEA__ HEADACHES__CONSTIPATION__SEIZURES RESPIRATORY __TROUBLE SWALLOWING__MEMORY LOSS __WHEEZING__DIZZINESS __COUGH MALES ONLY__FAINTING (PASSING OUT) __COUGH UP BLOOD __HERNIA__NUMBNESS __SHORTNESS OF BREATH __BLOODY EJACULATION__WEAKNESS __LUMP ON TESTICLESKIN __DISCHARGE FROM PENISEARS, NOSE, THROAT __ACNE __PROBLEMS ACHIEVING OR__RUNNY NOSE/SINUS CONGESTION __RASH MAINTAINING AN ERECTION__NOSE ITCHING __VERY DRY SKIN __SORE OR WARTS ON PENIS__SORE THROAT __JAUNDICE __TESTICULAR PAIN/SWELLING__GOITER __IRREGULAR OR CHANGING MOLES__HOARSENESS FEMALE ONLY__SWOLLEN GLANDS(NODES) KIDNEY & URINARY TRACT __HOT FLASHES__HEARING LOSS __BLOOD IN URINE __ABNORMAL VAGINAL BLEEDING__ EAR PAIN __BROWN URINE __ABNORMAL PAP SMEAR__PAINFUL URINATION __SEVERE MENSTRUAL PAINEYES __URINE LEAKAGE __HEAVY BLEEDING DURING CYCLES__DOUBLE VISION __FREQUENT URINATION __DISCHARGE FROM BREAST__VISION LOSS __DIFFICULTY URINATING __SEVERE PMS (PREMENSTRUAL SYNDROME)__VAGINAL DISCHARGEMUSCULOSKELETAL MALE & FEMALE __VAGINAL DRYNESS__JOINT SWELLING __PAINFUL INTERCOUSE __VAGINAL WARTS__MORNING STIFFNESS __UNPROTECTED SEX__MUSCLE PAIN __ANY CONCERNS ABOUT SEXUALLY PSYCHIATRIC__JOINT PAIN TRANSMITTED DISEASES __DEPRESSED MOOD__ANXIETYENDOCRINE __PROBLEMS W/ RELATIONSHIP__INCREASED BODY HAIR __UNUSUAL FEAR OF _____________________________CHANGES IN SKIN TEXTURE __DRUG ADDICTION_______________________________COLD INTOLERANCE __CHANGE IN SLEEP PATTERNS__HEAT INTOLERANCE__INCREASED LOSS OF HAIRSundance Family Medical CenterlefttopConsent to the Use and Disclosure of Health InformationFor Treatment, Payment, or Healthcare OperationsI understand that as part of my healthcare, this organization originates and maintains health recordsdescribing my health history, symptoms, examination and test results, diagnoses, treatment, and myplans for future care or treatment. I understand that this information serves as:? a basis for planning my care and treatment? a means of communication among the many health professionals who contribute to my care? a source of information for applying my diagnosis and surgical information to my bill? a means by which a third‐party payer can verify that services billed were actually provided? and a tool for routine healthcare operations such as assessing quality and reviewing thecompetence of healthcare professionalsI understand that I have been provided with a Notice of Privacy Practices that provides a more completedescription of information uses and disclosures. I understand that I have the right to review the noticeprior to signing this consent. I understand that the organization reserves the right to change their noticeand practices prior to implementation will mail a copy of any revised notice to the address I’ve provided.I understand that I have the right to request restrictions as to how my health information may be usedor disclosed to carry out treatment, payment, or healthcare operations and that the organization is notrequired to agree to the restrictions requested. I understand that I may revoke this consent in writing,except to the extent that the organization has already taken action in reliance thereon. I understandthat I may request my own copy of Notice of Privacy Practices to keep.We use an electronic health record in our office. This allows us to maintain more accurate and secureinformation about your health. It also gives us access to insurance companies and pharmacies.I request the following restrictions to use or disclosure of my health information:______________Accepted _______________DeniedSignature of patient_______________________________________________Date: ________________________________Print name: _____________________________________________________________________________________Signature of Legal Representative Witness ______________________________________________________________________Print name: _____________________________________________________________________________________Date Notice Effective Date or Version _________________________________________________________lefttopPatient Name: ______________________________________ DOB _________________Prescription Refill PolicyPlease initial your name next to each number.___ 1) Refills are done during appointments; we try to take care of any refills that will be needed before the next visit at each appointment. Therefore, you never should find yourself without refills between visits.___ 2) if you are running out of a medication, check to see when you were instructed to return for a follow up visit. If due for a visit, please schedule an appointment rather than calling to request a refill.In some limited circumstances, you may need a refill between appointments; for example, if we did not send your refill at the last appointment as intended or if it did not go through.___3) Remember the first step to follow if you think you are out of refills is to check when your appointment is due, second is to call your pharmacy and speak with a live person. Ask the pharmacy if you have refill on file that we may have sent ahead for you. If not ask the pharmacy to send us a faxed request. We prefer to not take prescription refill request by phone. Our staff and our phone lines need to be available for the urgent medical needs of our patients.___ 4) We request 7 days advance notice for all prescription refill requests that are not received at the time of an office visit. ___ 5) If you need a refill for narcotic pain medicine please make an appointment so that we may determine if the refill is appropriate.___ 6) No more than a 30 day supply will be written for a patient who has not returned for regularly scheduled follow up visit; in some cases less than a 30 day supply may be appropriate. We reserve the right to ask a patient to be seen by their doctor before the refill is granted.___ 7) No refills will be given to a patient: (A) who has never been seen by us, (B) who has not been seen at our clinic in the past year and, (C) who does not return for follow up appointments.___ 8) Some medications may need more urgent attention to refill than others. These may include some blood pressure medications, beta-blocker, and others. It is especially important to keep your follow up appointment on time for these medications and to check ahead on your supply to be able to give a 7 day advance notice, but if you do find yourself with a more urgent need, first call your pharmacy and follow steps above, but also call us if needed.No Show PolicyEach of our physicians sees only a fixed number of patients per day, so that we can devote our full energy to their issues. We do not make it our practice to overbook patients. Advance notice to cancel an appointment allows us to put in another patient who may need to be seen urgently. Also, given the limited number of appointment each day, we count on these visits in order to operate our practice successfully. Therefore, we have established the following policy as regards to missed appointments / no shows/ late cancellations.___If you need to cancel an appointment, please notify us as early as possible; we request at least 48 hours advance notice and at the very least,24 hours (1 BUSINESS DAY) advance notice. For a no show appointment, or cancellation with less than 24 business hours notice, there will be a NO SHOW FEE of $50.00. This fee is not billable to insurance and must be paid by you directly.We will attempt to contact you ahead of your appointment, to confirm the appointment but please keep in mind that the primary responsibility rests with you, the patient, to keep the appointment in your calendar with a reminder system that works for you, in case we do not reach you.Atsushi Matsubara M.D.Norma Anderson M.D.Patient Signature _____________________________________________________ Date __________________________ ................
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