New Patient Package

Craig A. Rinder, MD, LLC

To Our Valued New Patient:

Welcome to our practice. It is our goal to make your experience with us as positive as possible. You may help us accomplish this in the following ways.

Having a complete medical history is essential if we are to provide you with the best care possible.

Please complete all parts of your New Patient Questionnaire and mail back to our office at:

375 Canal Street

Brattleboro, VT 05301

When we receive you packet back we will contact you to schedule your appointment.

v  Please arrive 15 minutes early so that we may complete the registration process.

Have your insurance cards and a photo Id ready for us to copy and be prepared to pay any deductable, co-payments, or co-insurance that is due at the time of service.

v  Be prepared to provide us with a urine specimen when you arrive.

v  If the patient is a minor, then a parent must be present for us to examine the patient.

If you are in a wheelchair and need assistance getting into our building or transferring to the exam table, please bring someone with you  OR let us know in advance so we will be prepared to help you with this process.

v  If you have no insurance, please let us know prior to your appointment. We do not finance any balances, however we do offer a program that will finance you for up to 18 months at 0% interest and we can pre-qualify you.

Thank you very much for your cooperation!

The directions are as follows: Take I-91 North / South to exit 1, go right / left off the exit. You will continue to go towards the center of Brattleboro. Going straight through the first set of lights, about 500 yards after the light (just before Belmont Ave and Brattleboro Memorial Hospital) on your left you will see a large stucco house on the corner. That is our office. The driveway is right before the house. You must enter the driveway from Canal Street. If you have any questions please feel free to call us.

Sincerely,

Bonnie Symanski

Urology & Urologic Surgery

We respectfully request that if you cannot make your appointment you provide us with 24hrs notice or you may be subject to a $175.00 charge for not showing.

CRAIG A. RINDER, MD             UPDATED__________________________

NAME________________________________________________________________DATE OF BIRTH________________

ADDRESS_________________________________________________________CITY______________________________

STATE_________ZIP______________PHONE_______________________________________MARITAL STATUS______

IS IT OKAY TO LEAVE A MESSAGE AT YOUR HOME FOR REMINDER APPOINTMENTS?  YES     OR      NO

SOCIAL SECURITY #________________________________EMPLOYMENT____________________________________

IF PATIENT IS A CHILD WE MUST HAVE THE PARENTS NAME

WORK           PHONE______________________________PARENT/SPOUSE____________________________________

INSURANCE   COVERAGE____________________________SUBSCRIBER NAME_______________________________

SOCIAL SECURITY # OF SUBSCRIBER_____________________

ID #’S_____________________________________________________GROUP #’S__________________________________

HOW MUCH IS YOUR DEDUCTIBLE? $________________ DO YOU HAVE A COPAY/ IF SO HOW MUCH? $________

WE ACCEPT PERSONAL CHECKS, CREDIT CARDS, CASH OR YOU CAN FINANCE THROUGH CARE CREDIT. THERE ARE NO PAYMENT PLANS OFFERED THROUGH OUR OFFICE, THEY ARE ALL DONE THROUGH CARE CREDIT. THIS IS INTEREST FREE FOR UP TO 12 MONTHS FOR QUALIFIED PATIENTS.

WHO IS YOUR PRIMARY CARE DOCTOR? _____________________________________PHONE____________________

WHAT PHARMACY DO YOU USE? _____________________________________ PHONE _____________________

Please read the following very carefully and initial each item below

_______ASSIGNMENT OF BENEFITS

I hereby authorize Craig Rinder, MD, LLC to furnish information to my insurance carrier (s) concerning my illness and treatment and to bill my health insurance carrier for reimbursement for services provided. I understand that I am ultimately responsible for the cost of the care that I receive. In particular, I agree to pay any amounts not covered by insurance, including co-payments, deductibles and non covered services (including obtaining the necessary referrals as required by your insurance carrier).

_______CONSENT TO TREAT

I do hereby give consent to Dr. Rinder and staff under his supervision to provide medical care and treatment.

_______PRIVACY POLICY

I have been given the opportunity to review the privacy policy of Craig Rinder, MD, LLC and agree to its terms.

_______RELEASE OF MEDICAL RECORDS

I do hereby request that my medical record, currently in the possession____________________________________________

Be released to Craig Rinder, MD.

Specific information requested: _____________________________________________________________________________.

I request the release of information relating to (circle all that apply):

Treatment of sexually transmitted disease

HIV status

Treatment of psychiatric conditions

Substance abuse treatment

Signature___________________________________________________________________Date______________

Comprehensive Medical History for Urology Patients

Your name:  _______________________________ Date of birth:  _____________________________

Physician who referred you:  _______________________________________

Your primary health care provider:  _______________________________________

Name of person completing this form (if other than patient):___________________________________

Present Illness: Describe in your own words your reason for coming to see the doctor today.  ____________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________How long have you had this problem?  ______________________________________________________________________________________

How severe is it?  ________________________________________   Have you ever had this problem before?  ____________________________

Is this problem always there?  ______________________________

What makes your symptoms worse?  ______________________________________________________________________________________

What makes you symptoms better?  ________________________________________________________________________________________

Is there anything else seems to be related to your main problem?  _________________________________________________________________

Is there something else you would like to discuss?  ____________________________________________________________________________

Past Medical History: Please list all medical conditions, past and present, for which you have been under the care of a physician.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Please list all surgical procedures and operations that you have had, including dates.

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Have you ever had an infection of the kidneys, bladder or urinary tract?  ____________________  , sexually transmitted disease?

______________________________ ,  kidney stones?  ___________________________ , diabetes?  ______________________,

heart disease?  ______________________, stroke?  _________________________.

Female patients: How many times have you been pregnant?  ___________How many children have you had?  ______________

Were there any problems with any of your pregnancies?  _______________________________

Children: Are all immunizations up to date?  _________________________  Have there been any problems relating to birth, growth or development?  _______________________  Is toilet training complete?________________ At what age? _______

Medications: List all medications you are currently taking, including aspirin, non-prescription medications and herbal or homeopathic products.Name of medication                                                    Dose                                          Reason for taking

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Allergies: List all medications to which you have had a reaction in the past, allergic or otherwise.

Name of medication                                             Type of reaction

_______________________________________________________________________________________

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Family History: Please list any medical problems that run in your family, including birth defects, high blood pressure, heart disease, diabetes and cancer (list specific types, if known.).  ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are your parents living?  ______________________________________________    What are their ages (or age at death, if deceased)?  ____________________________

What medical problems has your mother had?  ____________________________________________________________________________________________________

What medical problems has your father had?  _____________________________________________________________________________________________________

Social History: Occupation:  ___________________________  Marital status:  _____________________  Do you live alone?  ____________________

Have you ever used tobacco?  ______________  If so, what type?  ____________________  How much?  _________________  For how many years?  ______________

Do you drink alcohol?  _____________  If so, how much?  __________________  Have you ever had a problem with alcoholism?  _____________________

How much coffee do you drink?  ______________  tea?  _____________  water?  _____________  soda?  _____________  What kind of soda?  __________________

Review of Systems: In the past 6 months, have you experienced any of the following?  Please explain any yes answers in the space to the right of each column.Constitutional Symptoms                                                                    Genitourinary

Fever                                                                                                       Painful urination

Chills                                                                                                       Blood in the urine

Sweats                                                                                                     Difficulty starting urination

Weight change more than 10 lbs.                                                                            Slow urine stream

Loss of appetite                                                                                       Urinary frequency

Urgency

Eyes Do you wake at night to urinate?  _______  How many times?  ________

Blurred vision                                                                                         Straining to urinate

Double vision                                                                                          Incontinence/leakage of urine

Eye pain                                                                                                  Inability to empty the bladder

Other                                                                                                       Adult male patients:

Difficulty with erections

Ear, Nose, Throat, Mouth Pain during or after sex

Loss of hearing                                                                                                       Other problems with sexual function

Ear pain                                                                                                                   Infertility

Sore throat                                                                                                               Adult female patients:

Sinus problems                                                                                                       Abnormal vaginal bleeding

Other                                                                                                                       Vaginal discharge

Infertility

Respiratory Painful intercourse

Cough                                                                                                                     Other sexual dysfunction

Shortness of breath

Wheezing                                                                                                                Endocrine

Other                                                                                                       Excessive thirst

Excessive hunger

Cardiovascular Heat intolerance

Chest pain or pressure                                                                                             Cold intolerance

Leg pain with exercise                                                                             Severe fatigue

Varicose veins

Other                                                                                                       Integumentary

Skin rash

Gastrointestinal Persistent itch

Abdominal pain                                                                                       Boils or other skin infections

Nausea or vomiting                                                                                 Other

Constipation

Diarrhea                                                                                                  Musculoskeletal

Other                                                                                                       Pain or stiffness of the back, neck or joints

Bone pain

Immunologic Muscle pain

Allergies                                                                                                  Other

Frequent or recurrent infections

Other                                                                                                       Lymphatic/hematologic

Unusual lumps or masses

Neurologic Abnormal bleeding or bruising

Headaches                                                                                                               Blood clots

Weakness

Numbness or tingling                                                                                              Psychiatric

Fainting or loss of consciousness                                                                           Depression

Tremor                                                                                                    Substance abuse

Other                                                                                                       Other

To the best of my knowledge, the answers I have given on this form are true and complete.

Signature:  _________________________________ Date:  __________________________