Dear Patient, Your appointment with Dr. Garza will begin with our Nurse who will review your medical Robert W. Beart, M.D. history, pharmacy and medication information. Medical Director Colorectal Surgery Institute After you complete your visit with our nurse, Dr. Garza will discuss the nature of your Petar Vukasin, M.D. Colorectal Surgery problem with you. Dr. Garza may perform an examination, which may include an anoscopy or proctoscopic examination. AnaMaria Garza, M.D. Colorectal & General Surgery Jocelyn Moon, PA-C IMPORTANT – PLEASE BRING THE FOLLOWING ITEMS WITH YOU FOR YOUR APPOINTMENT: The enclosed Patient Questionnaire forms – please be sure to complete these before arriving for your appointment, including pharmacy and medications. All insurance cards, claim forms and drivers license. Pertinent operative reports, pathology reports, x‐ray films and their reports, diagnostic tests and their reports, and lab reports from your current physician. Should you have any questions, please feel free to contact me by phone at 818‐244‐8161, or e‐mail at [email protected] We look forward to meeting you and the opportunity to participate in your care. Sincerely, Colorectal Surgery Institute Attachments: Patient Medical History (Please complete) Patient Information (Please complete) Consent Form (Please complete) CSI‐GMH Patient Billing Information Conditions of Admission ‐ Glendale Memorial Hospital Maps and Directions – Glendale Memorial Hospital & Colorectal Surgery Institute 222 West Eulalia Street Dignity Health Glendale Memorial Hospital and Health Center Suite 100A and their team of Gastrointestinal Physicians and Surgeons Glendale, CA 91204 HEALTHGRADES 2014‐2015 CLINICAL AWARDS: PH 818.244.8161 FAX 818.244.5122 Gastrointestinal Care Excellence Award colorectalsurgeryinstitute.org Five‐Star Recipient for Colorectal and Small Intestine Surgeries PATIENT MEDICAL HISTORY Date: / / Name: Age: Sex: Race: Marital Status: S M Div Wid Sep Occupation: Referring Diagnosis: REFERRED BY: Physician Glendale Memorial Hospital Family Friend Website Facebook REFERRING PHYSICIAN: Address: City: State: Zip: PLEASE LIST THE NAMES OF OTHER PHYSICIANS CARING FOR YOU Primary Care Physician: Name: City/State: Internist: Name: City/State: Gastroenterologist: Name: City/State: Cardiologist: Name: City/State: Oncologist: Name: City/State: Other: Name: City/State: CHIEF COMPLAINT (and duration): HISTORY OF PRESENT ILLNESS: FAMILY HISTORY OF COLON PROBLEMS: FAMILY HISTORY OF ANY TYPE OF CANCER: LIST PERTINENT FAMILY, SOCIAL &/OR PERSONAL HISTORY Use This Space for Additional Information Anesthetic Complications: Alcohol: Tobacco: Recreation Drugs: LIST ALL PREVIOUS SURGICAL PROCEDURES & COLONOSCOPIES Date: Date: Date: Date: Date: PATIENT LABEL Page 1 of 3 CHECK APPROPRIATE BOXES – No check means not asked Have You Ever Had: Yes No ? Major trauma YOUR PHARMACY CONTACT INFORMATION: Yes No ? Heart attack or heart condition Pharmacy name: Yes No ? Stroke/TIA Address: Yes No ? Alcoholism/Drug Abuse Yes No ? Diabetes Type I-II Phone: ( ) Fax: ( ) Yes No ? Venereal disease Yes No ? Communicable disease such as TB, Typhoid fever, Amebiasis, etc. Yes No ? Hepatitis LIST ALL DRUGS THAT YOU TAKE ROUTINELY Yes No ? MRSA, CDIFF Drug Dose/Day How Long Yes No ? Blood or plasma transfusion reaction Yes No ? Horse serum (TAT, GAT) reaction Yes No ? Penicillin or Sulfa reaction Yes No ? Anxiety, depression, bipolar Yes No ? Increased cholesterol Yes No ? Increased triglycerides Yes No ? Chronic heart failure Yes No ? Renal insufficiency/failure Yes No ? Cancer Yes No ? Blood thinners Yes No ? Asthma, emphysema, COPD (chronic Obstructive pulmonary disease) Yes No ? Autoimmune Disease Other: LIST ALL KNOWN DRUG (OR OTHER) ALLERGIES BELOW AND TYPE OF REACTION (I.E.: RASH, ANAPHYLAXIS, SHORTNESS OF BREATH, ETC.) WITHIN THE PAST SIX MONTHS, HAVE YOU TAKEN: Drug Reaction Yes No ? Digitalis Yes No ? Anti-convulsants Yes No ? Anti-hypertensive agents Yes No ? Corticosteroids Yes No ? Narcotics Yes No ? Blood thinners Use This Space for Additional Information IMMUNIZATION HISTORY: Tetanus Date: Pneumonia Date: Influenza Date: Polio Date: Measles, Mumps, Rubella Date: Other Date: REVIEW OF CURRENT SYMPTOMS: Check appropriate box GENERAL: Yes No ? Chills Yes No ? Fever Yes No ? Weight Change Yes No ? Skin Change PATIENT LABEL Page 2 of 3 – Patient Medical History Review of Current Symptoms (continued) EYES: Use This Space for Additional Information Yes No ? Loss of Vision Yes No ? Double Vision Yes No ? Eye Pain ENT: Yes No ? Ear Pain Yes No ? Deafness Yes No ? Bleeding Nose Yes No ? Hoarseness Yes No ? Difficulty Swallowing CARDIORESPIRATORY: Yes No ? Cough Yes No ? Chest pain or Shortness of Breath Yes No ? Blood with Coughing Yes No ? Leg Swelling GASTROINTESTINAL: Yes No ? Poor Appetite Yes No ? Nausea and Vomiting Yes No ? Constipation or Diarrhea Yes No ? Change in Bowel Habits Yes No ? Jaundice Yes No ? Abdominal Pain Yes No ? Anal Bleeding Yes No ? Anal Pain GENITOURINARY: Yes No ? Frequency, Urgency, or Incontinence Yes No ? Urgency Yes No ? Blood in Urine Yes No ? Stones or Gravel Yes No ? Urethral Discharge Yes No ? Incontinence NEUROPSYCHIATRIC: Yes No ? Headaches Yes No ? Seizures Yes No ? Paralysis Yes No ? Anxiety/depression Yes No ? Disturbance of Gait or Speech Yes No ? Disturbing Feelings or Thoughts MUSCULOSKELETAL: Yes No ? Back Pain Yes No ? Bone Infections Yes No ? Skeletal Deformities Yes No ? Joint Pain or Swelling Yes No ? Varicose Veins Yes No ? Leg Ulcers OB-GYN # Pregnancies # Vaginal Deliveries # C-Sections Yes No ? Episiotomy – If yes, # Yes No ? Non-menstrual bleeding Yes No ? Excessive Menstrual Flow Yes No ? Irregular Menstrual Flow Yes No ? Pelvic Pain Last Menstrual period PATIENT LABEL Page 3 of 3 – Patient Medical History PATIENT INFORMATION Date: / / Name: Date of Birth: / / _ Sex: M F First Name Middle Initial Last Name Home Address: Street Address City, State Zip Code Home Phone: ( ) Cell Phone: ( ) Other Phone: ( ) Preferred Phone: Home Phone Cell Phone Other Phone Marital Status: Married Divorced Legally Separated Life Partner Single Widowed Unknown Race/Ethnicity: Asian-Pacific Islander Black-African American Caucasian Hispanic American Indian Eskimo Other Primary Language: Religious Preference: Occupation: Social Security #: Employment Status: Full Time Part Time Self Employed Unemployed Retired Active Military Duty Do You Have Advanced Directives: Yes No If Yes, please bring a copy to the hospital Emergency Contact: Relationship: First Name Middle Initial Last Name Home Phone: ( ) Cell Phone: ( ) Other Phone: ( ) Address: Street Address City, State Zip Code PATIENT LABEL AnaMaria McElrath‐Garza, M.D. Consent Form 1. CONSENT FOR TREATMENT I hereby authorize my consent to be treated now and in the future by Dr. AnaMaria McElrath‐Garza. 2. ASSIGNMENT OF BENEFITS I hereby authorize Dr. McElrath‐Garza to furnish information to insurance carriers concerning this illness. I hereby irrevocably assign to Dr. McElrath‐Garza all payments for medical services rendered and all major medical benefits. 3. MEDICARE AUTHORIZATION TO RELEASE INFORMATION & PAYMENT REQUEST I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign benefits payable for physician’s services to the physician or organization furnishing the services. 4. RELEASE OF INFORMATION FOR BENEFITS I authorize release of any information acquired in the course of my examination or treatment, which may be needed for the payment of professional charges and related services. 5. RELEASE OF INFORMATION TO COLORECTAL AFFILIATES I authorize the release of my medical information to other facilities for the purpose of diagnosis and treatment at the request of my physician, or its disclosure is required or permitted by law. 6. FINANCIAL AGREEMENT I understand that charges for facility, any diagnostic tests will be in addition to the consultation fee, and that I am directly financially responsible for all charges, including deductibles and co‐payments incurred for medical services and/or surgical procedures rendered for myself and/or my dependents whether or not they are covered by valid insurance benefits and any balance due and owing for all non covered out of the network services. I understand that if I am in an HMO and elect to see Dr. McElrath‐Garza using my out of network benefits then Dr. McElrath‐Garza will not retroactively put the billing through as though she were within the HMO. I agree to pay any legal interest, collection expense, and attorney’s fees or other costs incurred should it become necessary to assign any amount I may owe for collection. 7. PERSONAL AFFIRMATION I certify that all statements given to Dr. McElrath‐Garza and personnel are complete and accurate to the best of my knowledge. A copy of this agreement should be considered as effective and valid as the original. This agreement will continue until revoked by me in writing. Patient Name Medical Record # Date Patient/Guarantor Signature (Guarantor Relationship) Date Witness Signature Remarks 222 West Eulalia Street Suite 100A Glendale, CA 91204 PH 818.244.8161 FAX 818.244.5122 colorectalsurgeryinstitute.org Colorectal Surgery Institute / Glendale