New Patient Information

Patient Name:

Date of Birth:

Sex:

Street Address:

City:

Zip Code:

Best Phone Number:

Cell phone:

Insurance:

Insurance Identification Number:

Sunscriber ( whose name is the insurance under)

Social Security Number of Insured subscriber:

The area of most concern ( nose, lungs, skin)

If patient is a minor, name of primary guardian:

PREPARATION

Please plan on spending at least 1.5 hours in this visit. The exam rooms are small, please limit the number of people you bring to the absolute minimum - if possible, place other children with alternative care so you you may devote attention to the consultation. Feel free to bring a recording device if there are other family members who want to hear what is said.

YOU MUST HAVE A PRIMARY CARE PHYSICIAN

I believe in the concept of a central managing person - a primary care doctor. I am merely a consultant. I do not have laboratory or X-ray equipment in the building which is necessar for efficient primary care. If you don't have one, we can assist you in choosing one and visiting them when you are ill. As a team, we can put together a plan for your care.

BE ON TIME FOR YOuR APPOINTMENT - WE DON'T USUALLY RUN LATE

Make plans to be here a bit early - if you are late, we may have to reschedule - no kidding.

DON'T STOP YOUR ASTHMA MEDICATIONS
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STOP ANTIHISTAMINES FOR A WEEK BEFORE YOUR VISIT: For a list - click on the question mark.
This is to make it possible to do limited skin testing - as below.

Notice of Privacy Practices

There are Federal regulations protecting your privacy. For an explanation of those regulations, click on the queston mark at the end of this sentence.

PATIENT CONSENT:

I agree that you may conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly, obtain payment from third party payers, and conduct normal health care operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent (See question mark above for HIPPA regulations). I understand that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

I understand that as a patient seeing Dr. Bob Lanier, I will undergo physical examination including nose, ears, throat and chest ,and be identified by photograph for internal purposes along with photographs of skin tests. You will be provided with copies of anything done in the office. I also understand it may be necessary to have skin testing to determine what type of allergies I may or may not have. I understand there may be a local reaction on the surface of the tested area that could cause some itching with some discomfort. In rare cases, there could be a feeling of tickling in the throat or shortness of breath. This reaction would be evaluated by the physician or nurse practitioner and depending upon the severity of the reaction, epinephrine and/or oxygen would be administered.

		I understand and agree
		I do not accept

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Name __________________________________________ Date__________________________
( to be signed in office)

Thanks for doing this in advance - I promise it will reduce the wasted time you normally spend in Doctor visits because your appointment time does not have to be "padded" with extra time to get this crucial data. There are two forms to do - and there is a little overlap since these two forms go to different departments, and I have not yet learned how to merge them - sorry - and thanks. Bob Lanier MD