Male Patient Registration Form

Patient Registration Form
Patient Information
Name

First NameMiddle NameLast Name
Date of Birth
SSN
Marital Status
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Preferred method of contact for reminder calls

VoicemailTextEmail
If voicemail, please select preferred number

PrimarySecondary
Race
Ethnicity
Employment and Pharmacy Information
Current Employer
Preferred Pharmacy
Pharmacy address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have an advanced directive?

YesNo
Emergency Contact
Contact Name

First NameLast Name
Contact Phone
Please enter a valid phone number.
Relationship
Primary Insurance
Insurance Co Name
ID#
Policy Holder’s Name

First NameLast Name
Policy Holder’s Date of Birth
Secondary Insurance
Insurance Co Name
ID#
Policy Holder’s Name

First NameLast Name
Policy Holder’s Date of Birth

Current Medications

(If You Take a Blood Thinner, Aspirin (Daily) or Insulin (Diabetes), please list below)
List Your Medications
Medication Allergies
Are you allergic to latex?

YesNo

International Prostatism Symptom Score (IPSS)
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
Over the past month, how often have you found you stopped and started again several times when you urinated?
Over the past month, how often have you found it difficult to postpone urination?
Over the past month, how often have you had a weak urinary stream?
Over the past month, how often have you had to push or strain to begin urination?
Over the past month, how often did you most typically get up to urinate from the time you went to bed at night until the time you got up the next morning?
Have you ever tried Flomax?
Have you had any previous prostate procedures?
Have you had a cystoscopy (internal inspection of the bladder)?

Additional Information
Do you need assistance walking?

NoneCaneWalkerWheelchair
Have you been hospitalized in the past 6 months?

YesNo
When/Why?
Release of Information Consent
Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis including treatment, payment and healthcare options.
Please list the family members or significant others, if any, whom we may inform about your medical condition only in an emergency.
Patient Acknowledgement
I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Bladder & Bowel Institute (BBI), associated providers, and other personnel. I am aware that the practice of medicine is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments at BBI.

I consent to the use and disclosure of my/the patient's protected health information for the purposes of obtaining payment for services rendered to me/the patient. I authorize payment of medical benefits to BBI or their designee for services rendered. I give permission to obtain all my medication/prescription history. I authorize any holder of medical information about me to release to the health care administration and its agents any information needed to determine these benefits or the benefits payable for related services.

I understand that the doctor may have ownership interest in a facility where my procedure may be performed. I understand that I have the right to choose where to receive services, including a facility where the physician does not have ownership interest.

I choose to receive communication from BBI by text or e-mail at the number or address stated above. I understand that such email and text may not be secure and there is a risk that they may be read by a third party.

I understand that my care provider creates and uses a record of my health history and related information that may be used for:

1. Continuing care and treatment.

2. A way of communicating with other health care professionals who are involved in my care.

3. A means of responding to insurers request for information about my care.

4. Review in quality assessment projects designed to help the clinic improve its ability to provide good health care.

My signature below authorizes the above uses of my records, consent, and treatment, and signifies that I was given a “Notice of Information Usage” or “Notice of Privacy Practices” and that this notice provides a more complex description of the ways my medical record might be used or disclosed when I registered as a patient of this clinic. I understand that the clinic’s policies about using information might change from time to time and that I can obtain another copy of the notice from Bladder & Bowel Institute.
To the best of my knowledge, the information provided above is accurate and complete.
Name

First NameLast Name
Date
Signature

Clear
Should be Empty:

Patient Registration Form

Patient Information

Employment and Pharmacy Information

Emergency Contact

Primary Insurance

Secondary Insurance

Current Medications

Patient Medical History

Major Medical Illnesses

Surgical History

Family History

Social History

Bladder Survey

International Prostatism Symptom Score (IPSS)

Additional Information

Release of Information Consent

Patient Acknowledgement