• NEW PATIENT FORM: ANESTHESIA

  • Hello and welcome to Bermuda Pain Relief Center. We ask that you help us by providing as much information as you can regarding your current condition and ongoing treatment as well as any prior diagnostic tests, treatments and medical records that you may have had. This questionnaire is designed to step you through all areas of your past and present medical care. Please complete as much of this form as you are able to prior to your first visit, so that we can use this information at the time of your first visit to get a complete picture of you and your overall condition. Please do not hesitate to ask any of our staff or physicians for assistance if you have any questions or concerns. We look forward to meeting you.

  • Date of birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Type of Health Insurance Coverage

  • I, hereby authorize Bermuda Pain Relief Center to collect, use, and release my health information as necessary to facilitate and coordinate my medical care. My health information may include, but is not limited to: Medical and office notes, Laboratory results, Radiology and imaging reports, Diagnostic test results, Treatment and consultation records and other information relevant to my medical care. I understand that my medical records may be shared with my General Practitioner, referring physician, and other healthcare providers involved in my care, as appropriate. I may request that the sharing of my medical information be limited to specific healthcare providers or specific types of information. I understand that I should notify Bermuda Pain Relief Center of any requested limitations.

     
    USE OF PATIENT PHOTOGRAPH AND IMAGE

    I consent to Bermuda Pain Relief Center obtaining and maintaining photographs or other images of me when they are reasonably necessary for my medical assessment, treatment, or documentation and as part of my medical record. I understand that such images will be treated as part of my confidential medical information and handled in accordance with applicable privacy laws and regulations.

     

    FINANCIAL POLICY AND AGREEMENT

    Bermuda Pain Relief Center is committed to providing patients with high-quality pain management services. Fees for consultations, procedures, and other services are based on the Center’s current specialist fee schedule. Patients are responsible for understanding the terms of their health insurance coverage, including their schedule of benefits, deductibles, co-payments, coverage limits, exclusions, and any other applicable requirements. Any applicable co-payment, deductible, or patient portion is due at the time of service, unless otherwise agreed upon with the Center. I understand that my insurance coverage is an agreement between me and my insurance provider, and that Bermuda Pain Relief Center does not guarantee payment or reimbursement by my insurance provider. I remain responsible for payment of all charges for services provided to me, regardless of whether my insurance provider pays the claim in full, in part, or declines payment. I authorize and request my insurance provider or other applicable third-party payer to make payment directly to Bermuda Pain Relief Center for eligible services provided to me. I understand that my insurance provider may reimburse an amount less than the Center’s actual charges, and I agree to pay any remaining balance for which I am responsible.

     

    CANCELLATION POLICY 

    Patients are asked to schedule appointments carefully and to provide as much notice as possible if an appointment must be cancelled or rescheduled.

    Cancellations with less than 24 hours' notice: A fee equivalent to 50% of the consultation fee may be charged.

    Missed appointments/no-shows: After three (3) missed appointments without appropriate notice, Bermuda Pain Relief Center reserves the right to decline further appointment scheduling.

    Late arrival: Patients who arrive after their scheduled appointment time may be required to reschedule their appointment, depending on the circumstances and the availability of the physician.

     

    I acknowledge that my physician may use AI-assisted documentation technology, including an AI-assisted scribe, to assist with the transcription, organization, and summarization of clinical information and dictated medical notes. I understand that the physician remains responsible for reviewing, editing, and approving my medical record before it is finalized. Any use of AI-assisted documentation will be conducted in accordance with applicable privacy, confidentiality, and health-information laws and regulations and the policies of Bermuda Pain Relief Center. I understand that I may decline the use of AI-assisted documentation during my visit by notifying the physician or a member of the Bermuda Pain Relief Center staff.

     

    I, confirm that I have read and understand the information contained in this Patient Consent, Privacy & Financial Agreement.

    I have had the opportunity to ask questions and have received satisfactory answers to my questions. I understand my responsibilities regarding the release of health information, financial obligations, insurance claims, appointment cancellations, and AI-assisted clinical documentation.

  • INFORMATION FOR SURGERY

  • SURGERY DATE*
     / /
    2 digit month, 2 digit day, 4 digit year

  • PREVIOUS/CURRENT MEDICAL HISTORY

  • Are you in General ,healthy?*
  • Do you now, or have you ever suffered with your:*
  • Do you suffer from fainting or epilepsy?*
  • Do you have any neuro muscular disease or weakness of any limbs? (e.g. Parkinson's, Multiple Scerosis)*
  • Do you have orthopedic problems? (e.g. arthritis, sciatica)*
  • Have you had any recent fall or injuries? (within one year)*
  • Do you have diabetes? Have you been told you have high blood sugar?*
  • Have you ever had thyroid problems?*
  • Do you have any blood disorders? (e.g. sickle cell, bleeding tendency)*
  • Do you have any gastrointestinal problems? (e.g. ulcers, hiatus hernia, ulcerative colitis)*
  • Have you ever been diagnosed with cancer?*
  • Do you have any problems with your eyes , ears or throat? (e.g. glaucoma, locking jaw, deaf)*
  • Do you have any loose, false teeth , capped teeth, bridges or dental work?*
  • Do you now or have you recently had a cold, sore throat, cough or blocked nose?*
  • Is there a possibility you may be pregnant?*
  • Do you suffer from mental illness?*

  • ANAESTHETIC HISTORY

  • Have you had any previous anaesthetics?*
  • Have you had any complications after anaesthetics, i.e. nausea?*
  • Have any blood relative ever had problems with general anaesthesics?

  • ALLERGY HISTORY

  • Are you allergic to any medications?*
  • Are you allergic to anything else?*

  • SUBSTANCE HISTORY

  • Do you smoke?*
  • Do you drink alcohol?*
  • Do you use any recreational drugs?*

  • Marijuana, cocaine, natural supplements, herbs etc... can affect your anaesthetic. Please inform the anaesthetist if any has been taken in the last week. 

  • EKG DATE
     / /
    2 digit month, 2 digit day, 4 digit year
  • X-RAY DATE
     / /
    2 digit month, 2 digit day, 4 digit year
  • BLOODWORK DATE
     / /
    2 digit month, 2 digit day, 4 digit year
  • HAVE YOU EVER HAD COVID
  • Are you taking any medications?*

  • Malignant Hyperthermia Questionnaire

  • Do you have any personal or family history of unexpected death following general anesthesia or exercise?*
  • Do you have a personal or family history of malignant hyperthermia?*
  • Do you have a personal or family history of a muscle or neuromuscular disorder?*
  • Do you have a personal or family history of a high temperature following exercise?*
  • Do you have a personal history of muscle spasms?*
  • Do you have a personal history of dark or chocolate colored urine?*
  • Do you have a personal or family history of unanticipated fever following anesthesia or serious exercise?*

  • If there is suspicious history, prior to surgery, you will be sent to genetic and/or caffeine-halothane contracture testing for Malignant Hyperthermia.

  • As I have had a general anaesthetic, I understand that I must not be in charge of any vehicle on the public road for 24 hours after my discharge from the surgical center.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: