2018-registration-packet

Patient Information
Last Name, First Name *
Last Name, First Name 2
Last Name, First Name 3
Last Name, First Name 4
Last Name, First Name 5
Last Name, First Name 6
Last Name, First Name 7
Middle Initial
Gender *

Male Female
Home Phone *
Cell Phone *
Social Security *
DOB *

Month Day Year
1 DOB *

Month Day Year
2 DOB *

Month Day Year
3 DOB *

Month Day Year
4 DOB *

Month Day Year
5 DOB *

Month Day Year
6 DOB *

Month Day Year
Email *
example@example.com
Email 1 *
example@example.com
Driver License
Occupation
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Name/Address

Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone
Name of Emergency Contact
Relationship
Emergency contact Phone *
Contact Preference

Home Phone Cell Phone
Referred to us/How did you hear about us?
Doctor Name
Hospital

Patient History Information
Marital Status
Referring Physician: *
Primary Care Physician:
1). What is the reason of your visit? *
2). Another reason for your visit?
Children Boys
Children Girls
Occupation
Recreation
Education Through
Grade Sleep
Exercise
Alcohol (type)
How Much
Quit
Tobacco (type)
How much
Quit
Tea, Caffeine
Race

American Indian or Alaska Native Asian Black or African American White Native Hawaiian or Pacific Islander Unknown-Decline
Ethnicity:
Past Medical History- Please include any exposure or infectious disease such as Covid 19, HIV, ect... *
Any History of HIV or Covid 19
Past Surgical History *
Family History *
Name of Pharmacy: *
Address of Pharmacy *

Address

Street Address Line 2

City State
Zip:
List of Allergies *
Medicine Taken Regularly /Reason/ Dose(Mg/ Day) *
Patient History and Review of System

General

Yes/No

Tire Easily Weakness

Persistent Fever

Skin

Yes/No

Eruptions (Rash)

Change in Color

Eyes

Yes/No

Trouble Seeing

Eye Pain

Nose

Yes/No

Loss of smell

Nosebleeds

Ear

Yes/No

Loss of hearing

Mouth

Yes/No

Dental Problems

Throat *

Yes/No

Hoarness

Cardio-Respiratory System

Yes/No

Cough, Persistance

Respiratory *

Yes/No

Shortenss of breath

Cardiac *

Yes/No

Chest pain or discomfort

Palpitation

Gastro Intestinal System *

Yes/No

Nausea

Vomiting

Musculo-Skeletal

Yes/No

Muscle Weakness

Pain in joints

Nervous System

Yes/No

Headaches

Dizziness

Infectious Disease *

Yes/No

Hepatitis

HIV

Genitourinary System *

Yes/No

Increase in frequency of urination(day)

Increase in frequency of urination (night)

Feel need to urinate without much urine

Slow stream

Hesitancy

Incomplete voiding

Pin or burning

Blood in urine

Urinary retention

Urgency

Urge incontinence

Leaking urine when coughing or sneezing

Do you use urinary products (pads) per day

Vaginal discharge

Pain at tip of penis

Testicular pain

Lump in testicles

Impotence

Lack of sex drive

Pain with intercourse

Patient Communication Consent form

I authorize The Urology Center of Southern California and medical staff to discuss my healthcare information(Which may include history, diagnosis, labs, test results, treatment and other health information) with the contracts listed below.
Authorized Name to release information to:
Relationship Contact Information
Patient /Guardian Signature: By my signature below, I acknowledge that I have read and understand the information provided on this consent form. *

Clear

Acknowledgement of Reciept of the Notice of Privacy Practices

I hereby acknowledge that I have read and received a copy of the Notice of Privacy Practices, with an effective date listed.
Patient Address: *
If not signed by the patient, please indicate Name and relationship: *
Signed: *

Clear
Other authorized personal representative: If not signed by the patient, please indicate name and relationship.
Patient Partnership Plan
Dear Patient,

Welcome to our practice. We intend to provide you with the care and service that you expect and deserve. Achieving your best possible health requires a “partnership” between you and your doctor. As our “partner in health,” we ask you to help us in the following ways:

Schedule Visits with My Doctor for Routine Physical Exams and Other

Recommended Health Screenings

I understand that my doctor will explain to me which regular health screenings are appropriate for my age, gender, and personal and family history. I understand I will need to complete these recommended health screenings (mammogram, immunizations, pap smears etc). These health screenings are tests that can help detect life-threatening diseases and conditions. If I visit my doctor only for treatment of immediate problems and forget to arrange for regular health screenings, I put myself at risk of letting serious health problems go undetected. I will schedule regular visits with my doctor to complete my physical exam and to discuss these health screenings.

Keep Follow-up Appointments and Reschedule Missed Appointments

I understand that my doctor will want to know how my condition progresses after I leave the office. Returning to my doctor on time gives him or her the chance to check my condition and my response to treatment. During a follow-up appointment, my doctor might order tests, refer me to a specialist, prescribe medication, or even discover and treat a serious health condition. If I miss an appointment and don’t reschedule, I run the risk that my physician will not be able to detect and treat a serious health condition. I will make every effort to reschedule missed appointments as soon as possible.

Call the Office When I Do Not Hear the Results of Labs and Other Tests

I understand that my physician’s goal is to report my lab and test results to me as soon as possible. However, if I do not hear from my physician’s office within the time specified, I will call the office for my test results.

Inform My Doctor if I Decide Not to Follow His or Her Recommended

Treatment Plan

I understand that after examining me, my doctor may make certain recommendations based on what he or she feels is best for my health. This might include prescribing medication, referring me to a specialist, ordering labs and tests, or even asking me to return to the office within a certain period of time. I understand that not following my treatment plan can have serious negative effects on my health. I will let my doctor know whenever I decide not to follow his or her recommendations so that he or she may fully inform me of any risks associated with my decision to delay or refuse treatment.

Thank you for your partnership. As our patient, you have the right to be informed about your health care. We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have.

If you need more information about your health or condition, please ask.
Patient Signature *

Clear
Physicians
S. Tsi M.D.; M. Reddy D.O.; F. Kim M.D.
Privacy Policy

This privacy policy discloses the privacy practices for https://patients.ucosc.com/patientportal/.

This privacy policy applies solely to information collected by this web site. It will notify you of the following:

What personally identifiable information is collected from you through the web site, how it is used and with whom it may be shared.
What choices are available to you regarding the use of your data.
The security procedures in place to protect the misuse of your information.
How you can correct any inaccuracies in the information.

Information Collection, Use, and Sharing

We are the sole owners of the information collected on this site. We only have access to/collect information that you voluntarily give us via email or other direct contact from you. We will not sell or rent this information to anyone.

We will use your information to respond to you, regarding the reason you contacted us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request, e.g. make a payment for services.

Unless you ask us not to, we may contact you via email in the future to tell you about specials, new products or services, or changes to this privacy policy.

Your Access to and Control Over Information

You may opt out of any future contacts from us at any time. You can do the following at any time by contacting us via the email address or phone number given on our website:

   • See what data we have about you, if any.

   • Change/correct any data we have about you.

   • Have us delete any data we have about you.

   • Express any concern you have about our use of your data.

Security

We take precautions to protect your information. When you submit sensitive information via the website, your information is protected both online and offline.

Wherever we collect sensitive information (such as credit card data), that information is encrypted and transmitted to us in a secure way. You can verify this by looking for a closed lock icon at the bottom of your web browser, or looking for "https" at the beginning of the address of the web page.

While we use encryption to protect sensitive information transmitted online, we also protect your information offline. Only employees who need the information to perform a specific job (for example, billing or customer service) are granted access to personally identifiable information. The computers/servers in which we store personally identifiable information are kept in a secure environment.

Updates

Our Privacy Policy may change from time to time and all updates will be posted on this page.

If you feel that we are not abiding by this privacy policy, you should contact us immediately via telephone at 951-735-2700 or invoices@ucosc.com.
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Patient Information

Patient Partnership Plan