PAiN MANAGEMENt CONSUltANtS, Pl - Fort Myers
FLORIDA PAIN CENTERS
Pain Management Consultants, pl
Gene D. Mahaney, MD Velimir A. Micovic, MD
Gilberto Acosta, MD Adam M. Shuster, DO Timothy D. Replogle, MD Michael D. Martinez, MD David S. Greschler, MD
7964 Summerlin Lake Dr., Fort Myers, FL 33907 ? Scheduling: 239-333-1177 ? Fax: 239-939-4733
Full Name __________________________________________ Address ____________________________________________ City ______________________________ State _________________ Zip ____________________
Re
Appointment scheduled for _______, at __________, with ______________
Please arrive 15 minutes prior to scheduled time for registration process.
Dear ______________: It is our pleasure to welcome you to Pain Management Consultants of Southwest Florida, PL.
In order to assure that your first visit with us goes smoothly, we have enclosed forms to be completed prior to your appointment. These forms are necessary to assist in your care. Mailing this packet to you in advance affords you the opportunity of filling it out at home at your convenience rather than doing so in the office where all the information needed may not be as accessible. This will save you time in the office, streamline the process and avoid the inconvenience of filling out these forms at the last minute. To expedite the registration process, we kindly ask that you bring the completed forms to our office at least one day prior to your scheduled visit. This will insure that all information is entered in our computer system prior to your visit and will expedite your registration process and afford our staff the necessary time to request additional records as needed. We understand that this may be an inconvenience, however, it is our goal to insure that you receive the highest level of care. For your convenience, our office has an after-hours mail drop to the right or our front door. If you are unable to return the packet prior to the day of your visit, kindly arrive 30 minutes prior to your scheduled appointment.
When you arrive for your initial visit and are being checked in, a member of our staff will ask for your insurance card(s) and Driver's License to scan, take your photo and have you electronically sign our HIPPA Privacy Compliance Notice. This information is collected to protect you as the patient from fraudulent activity.
Please be sure to bring the completed packet to our office at least one day prior to your scheduled appointment along with any recent (within the last 18 months) MRI, CT Scan (Cat Scan), X-ray or Physical Therapy reports. If you do not have copies, of your reports, please contact the rendering physician or facility and have them faxed to our office at 1-877-343-6571 prior to your appointment.
Again, we welcome you to our practice. If you have access to a computer, please visit our website at to find out how Pain Management Consultants of Southwest Florida, PL can help you. Our aim is excellence in patient care and to assist our patients in any way we can.
Sincerely, Scheduling Staff for Pain Management Consultants Enclosures
Form: 04/14/2018
New Patient Packet Page 1 of 15
FLORIDA PAIN CENTERS
Pain Management Consultants, pl
Gene D. Mahaney, MD Velimir A. Micovic, MD
Gilberto Acosta, MD Adam M. Shuster, DO Timothy D. Replogle, MD Michael D. Martinez, MD David S. Greschler, MD
PATIENT DEMOGRAPHIC INFORMATION
_________________________ _________________________ _________________________ _________________________
First Name
Middle Name
Last Name
E-mail Address
SSN:_____________________ DOB:_____________ Drivers License #:___________________________
_______________________________________________________________________________________________________
Address
City, State
Zip Code
Phone Number
_______________________________________________________________________________________________________
Northern Address
City, State
Zip Code
Phone Number
Patient Cell Phone:__________________________ Preferred Contact Phone #_________________
Patient Occupation:____________________________ Employer Phone:________________________
Employer Address: _______________________________________________________________________
EMERGENCY CONTACT INFORMATION
Spouse Name:_______________________________ Spouse DOB:______________________________ Spouse Cell Phone:___________________________ Spouse Work Phone:______________________ Spouse Employer & Address:_____________________________________________________________ Other Emergency Contact & Relationship:____________________________________________________________________________
HEALTH INSURANCE INFORMATION
Primary Insurance Name:________________________________________________________________ Insurance Subscriber_______________________________ Relation to Subscriber:_______________ Policy Number:_____________________________________ Group #____________________________ Claims Mailing Address:__________________________________________________________________ Phone Number:__________________________________________________________________________ Secondary Insurance name:_____________________________________________________________ Insurance Subscriber_______________________________ Relation to Subscriber:_______________ Policy Number:_____________________________________ Group #____________________________ Claims Mailing Address:_________________________________________________________________________________ Phone Number:__________________________
Form: 04/14/2018
New Patient Packet Page 2 of 15
FLORIDA PAIN CENTERS
Pain Management Consultants, pl
Gene D. Mahaney, MD Velimir A. Micovic, MD
Gilberto Acosta, MD Adam M. Shuster, DO Timothy D. Replogle, MD Michael D. Martinez, MD David S. Greschler, MD
PLEASE BRING THE FOLLOWING TO YOUR APPOINTMENT ON: ______ ? ALL PRESCRIPTION MEDICATION IN THEIR ORIGINAL CONTAINERS ? INSURANCE CARD ? ID CARD
? IMAGING FILMS/REPORTS (MRIs, X-RAYS, CT SCANS, PHYSICAL THERAPY REPORTS ETC.)
PATIENT HEALTH HISTORY - __________, Chart # _________________ For us to obtain a complete medical history, please fill out every item as this information is very important. Full Name:______________________________________________ DOB:____________________ Male_____ Female_____ Social Security Number:________________________ Primary Physician:________________________________ Primary MD Phone Number:____________________________ Pharmacy name & address:_____________________________________ Pharmacy Phone Number:__________________ Your Insurance Company's preferred Lab & Phone Number:___________________________________________________
Is This a Work Comp Case: No Yes Date of Injury:____________
Recent Auto Accident: NO
Yes (IF YES, MUST COMPLETE AUTO DISCLOSURE FORM) Date of Accident: _________
Past Injuries/falls ? Please list and provide dates:________________________________________________________________
Current Medications ? Are you taking ANY medications now including prescriptions, over-the-counter or herbal medication
NO YES If yes, please list below and include dosages. Bring all medications with you in their original bottles.
MEDICATION NAME
DOSAGE
HOW OFTEN TAKEN
Medication Allergies ? Are you allergic to ANY medications? No
MEDICATION
Yes (If yes, please list:)
TYPE OF REACTION
Please check if you are allergic to the following:
IODINE
Surgeries ? Have you had Bone, Joint, or Muscle surgeries?
TYPE OF SURGERY/PROCEDURE
SHELLFISH
LATEX
NO
YES (If yes, please list:)
DATE OF SURGERY/PROCEDURE
________, Chart # _________ Patient Health History Page 1 of 3
Form: 04/14/2018
New Patient Packet Page 3 of 15
FLORIDA PAIN CENTERS
Pain Management Consultants, pl
Gene D. Mahaney, MD Velimir A. Micovic, MD
Gilberto Acosta, MD Adam M. Shuster, DO Timothy D. Replogle, MD Michael D. Martinez, MD David S. Greschler, MD
Please list any specialists that have previously evaluated you for your pain: Neurologist: __________________________________________ Pain Physician____________________________________________ Neurosurgeon:________________________________________ Psychiatrist:______________________________________________ Orthopedic Surgeon___________________________________ Rheumatologist:__________________________________________ Osteopathic Physician:_________________________________ Rehab/Physiatrist:_________________________________________
TESTS: If you have had any of the following, please describe where, when and the results of your tests. Please bring a copy of the films/reports with you.
TEST X-Rays CT/MRI EMG/NCS (Nerve Conduction Studies) Myelogram Discogram
YES
NO
DATE
WHERE WAS IT DONE/FINDINGS
TREATMENTS: If you have had any of the following, please list when, where and if it was helpful. Please bring a copy of the reports with you.
Treatment
Acupuncture Alternative/Herbal Massage therapy Braces/splints/assistive devices Chiropractor Heat/Ice therapy Injection therapy Nerve blocks Over the counter meds Prescription meds Occupational therapy Physical therapy TENS Unit Traction Biofeedback Counseling Other
When
Where did you have the treatment Results of the treatment(s)/was the treatment helpful?
________, Chart # _________ Patient Health History Page 2 of 3
Form: 04/14/2018
New Patient Packet Page 4 of 15
FLORIDA PAIN CENTERS
Pain Management Consultants, pl
Gene D. Mahaney, MD Velimir A. Micovic, MD
Gilberto Acosta, MD Adam M. Shuster, DO Timothy D. Replogle, MD Michael D. Martinez, MD David S. Greschler, MD
What is the MAIN reason you are here today to see the Physician: _________________________________________ ______________________________________________________________
Please circle the types of pain you are having: Burning
Stabbing
Aching
Sharp
How long have you experienced this pain?
_______ Hours _______ Days _______Months ________Years
Please mark the body below in the location(s) you are having pain:
________________________________________ ________
Patient/Legal Guardian Signature
Date
________, Chart # _________ Patient Health History Page 3 of 3 Form: 04/14/2018
Form: 04/14/2018
Admitted by:_____________________ New Patient Packet Page 5 of 15
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