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.
v 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.
v 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.
|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________________
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
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.
_______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
Treatment of psychiatric conditions
Substance abuse treatment
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.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list all surgical procedures and operations that you have had, including dates.
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
Allergies: List all medications to which you have had a reaction in the past, allergic or otherwise.
Name of medication Type of reaction
|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
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
Respiratory Painful intercourse
Cough Other sexual dysfunction
Shortness of breath
Other Excessive thirst
Cardiovascular Heat intolerance
Chest pain or pressure Cold intolerance
Leg pain with exercise Severe fatigue
Gastrointestinal Persistent itch
Abdominal pain Boils or other skin infections
Nausea or vomiting Other
Other Pain or stiffness of the back, neck or joints
Immunologic Muscle pain
Frequent or recurrent infections
Unusual lumps or masses
Neurologic Abnormal bleeding or bruising
Headaches Blood clots
Numbness or tingling Psychiatric
Fainting or loss of consciousness Depression
Tremor Substance abuse
To the best of my knowledge, the answers I have given on this form are true and complete.
Signature: _________________________________ Date: __________________________