The Oregon Hemorrhoid Clinic – New Patient Information

The Oregon Hemorrhoid Clinic – New Patient Proctology Information

Please fill out all required fields and review your information before submitting.
New Patient Information
Legal Full Name*

First NameMiddle NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
FemaleMaleIntersexNon-binaryPrefer not to sayOther
She/Her/HersHe/Him/HisThey/Them
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
How did you hear about our clinic?
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Patient*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Contact Details (optional)
Insurance
Insurance Provider
Policy / Member ID
Group Number
Subscriber Name

First NameMiddle NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Relationship to Subscriber
Plan Type
Reason for Visit & GI History
HemorrhoidsRectal bleedingAnal painItching or irritationLump or swellingChange in bowel habitsTailbone painOther
PainBleedingSwellingItchingDischargeConstipationDiarrheaMucus in stoolOther
Other symptoms or details
How long have you had these symptoms?*
How often do symptoms occur?*
YesNoUnsure
Please describe the bleeding
ConstipationDiarrheaIBSInflammatory bowel diseaseAnal fissureHemorrhoidsColon polypsColon cancerAnal Fistula
Review of Systems
FeverChillsFatigueUnintentional Weight LossNight Sweats
RashItchingBruisingBleeding Easily
HeadachesVision ChangesHearing LossNasal CongestionSore Throat
CoughShortness of BreathWheezingSnoringCoughing Up Blood
Chest PainPalpitationsLeg SwellingFaintingExercise Intolerance
Abdominal PainNauseaVomitingDiarrheaConstipationBlood in StoolBlack StoolsChange in Bowel Habits
Please describe any other gastrointestinal symptoms
Musculoskeletal
Joint painMuscle painStiffnessWeaknessSwellingLimited range of motionOther
If you are visiting us for treatment of tailbone pain, please describe the history of the injury.
Gynecological History
YesNoUnsure
YesNo
Date of last menstrual period

MonthDayYear
Date
YesNoNot applicable
EndometriosisFibroidsOvarian cystsPelvic painOther
Please describe any other women’s health concerns or relevant details
Urinary and Prostate History
NoYes
Frequent urinationUrgencyWeak streamNighttime urinationDifficulty starting urinationPelvic discomfortOther
Date of last prostate exam

MonthDayYear
Date
NoYesPrefer not to say
Personal Medical History
DiabetesHigh blood pressureHeart diseaseStrokeCancerAsthmaCOPDKidney diseaseLiver diseaseThyroid disorderBleeding disorder
AppendectomyGallbladder surgeryHernia repairColonoscopyHemorrhoid procedureOther
If you selected Other for surgeries or procedures, please describe
NoYes
If yes, list your current medications and doses
NoYes
If yes, list the medication and the reaction
Family History
Colon cancerRectal cancerInflammatory bowel diseaseHemorrhoidsPolypsBleeding disorder
NoYesUnsure
If yes, please specify which relative and age at diagnosis
NoYesUnsure
If yes, please specify which relative and diagnosis
Please describe any other relevant family history or hereditary conditions
Social History
NeverFormerCurrent
NeverOccasionallyWeeklyDaily
Average exercise days per week
Treatment Authorization
Treatment authorization acknowledgment
Electronic signature*
Date signed*

MonthDayYear
Date
Office Policy & Privacy Acknowledgment
Office Policy and Privacy Policy

Office Hours:

Our office is open Monday thru Friday from 8:00am to 4:00pm. If an appointment cancellation is necessary, please notify our office at least 24 hours before the scheduled appointment. Less than 24 hours notice of cancelling an appointment will result in a $50 cancellation fee which will be billed to you directly.

Fees and Financial Policy:

Payment of fees is the direct responsibility of the patient. We collect payment at the time of service. You may pay by cash, check, Visa, Mastercard, or Discover.

Insurance Billing:

As a courtesy to you, we will bill your insurance company. When time allows, we will call and check your insurance befefits. This is not a guarantee that you will be covered, as benefits are determined when your insurance company processes your claim. Should the insurance deny your claim, we ask that you pay our office directly and contact your insurance company for any questions regarding non-payment.

Summary of Our Privacy Policy:

We strongly believe in maintaining your private healthcare information. We do not disclose any non-public information about you to anyone, except as permitted by law, or to process an insurance claim. We maintain physical and procedural safeguards that comply with Federal and State regulations to protect information about you. A complete copy of our privacy policy is available upon request.

Upon signing, you agree that: I have read and understand the above policies of this office, and I agree with them. I consent to treament with Dr. Brett J. Hubbard, and/or Dr. Steven L. Gardner, and/or Dr. Maria F. Siri, and/or Dr. Lauren R. Herschorn. I accept full responsibility for all expenses incurred by, or on the account of the patient. In the event of non-payment, I understand my account will be turned over to a collection company to pursue my balance, and I will pay the cost of collection and legal fees should that be required.
Electronic Signature*
Date*

MonthDayYear
Date
Should be Empty:

The Oregon Hemorrhoid Clinic – New Patient Proctology Information

New Patient Information

Emergency Contact

Insurance

Reason for Visit & GI History

Review of Systems

Musculoskeletal

Gynecological History

Urinary and Prostate History

Personal Medical History

Family History

Social History

Treatment Authorization

Office Policy & Privacy Acknowledgment