www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

Welcome to SOAR!

Thank you for choosing SOAR as your pain management provider. You will find enclosed the new patient paperwork, your appointment information and a map to your chosen facility. If you have any questions or concerns, please feel free to contact the New Patient Coordinator. To help expedite your treatment, to ensure your privacy and to correctly file your insurance claims, we ask that you carefully read over the following information and provide the required identification. 1.

Please provide our office with your correct insurance card (primary, secondary and tertiary) and photo identification, such as driver’s license and social security card. It is required these items are to be submitted at the time you checkin.

2.

Please provide your most recent medical records, which would include any imaging reports pertaining to your condition. If your PCP (primary care physician) referred you to our office, please contact them to request that they submit any medical records and/or imaging reports to our office. If you are a self-referred client, please obtain the medical records pertaining to your pain and either bring them to your appointment or have them faxed (321-7337970). It is your responsibility to ensure that these records are provided to our physicians.

3.

It is your responsibility to obtain authorization for any office visits including your initial consultation if your insurance requires said authorization. This would be obtained from your PCP. Please ensure that your PCP has your correct insurance information when requesting an appointment to our facility. If an authorization is not obtained and is required, you may incur fees from your visits.

4.

Finally, there may come a time when you require additional medical and/or insurance forms to be completed by our office. They may include, but are not limited to, Disability Forms, Workers’ Compensation Forms, Attending Physician Statement, Leave of Absence forms, etc. This will not apply to most patients. However, in order to accommodate these requests, it will necessitate reviewing the chart, staff time and office resources. Therefore, a reasonable fee for such services will be applied. The fee for completing said forms is $150.00. Forms will not be completed until this fee is received. Every effort will be made to have these forms completed within a 5-7 business day turn-around from the time the fee is received. Please note that if the provider is out of the office there may be a longer delay. This would only apply to completing and filling out above-mentioned forms and NOT for completing the enclosed paperwork you received as a new patient to our facility.

Please arrive at your scheduled appointment 30 minutes prior to your appointment time and bring the completed paperwork you received from our office, insurance cards and photo identification. Please note that photo identification is REQUIRED at the time of appointment for any patient and failure to provide said photo identification will result in a cancellation of the appointment. If you have any questions, please feel free to contact this office. Thank you for choosing SOAR. Sincerely,

SOAR

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

PLEASE FILL OUT THIS INFORMATION COMPLETELY. LAST NAME

FIRST NAME

MIDDLE

HOME PHONE

CELL PHONE

DATE OF BIRTH

MARITAL STATUS

SOCIAL SECURITY

DRIVERS LICENSE #

WORK PHONE

MAR

DIV

SINGLE

STREET ADDRESS

CITY, STATE

EMERGENCY CONTACT

EMERGENCY CONTACT PHONE NUMBER

PHARMACY NAME

ADDRESS

ZIP

PHONE NUMBER

PRIMARY INSURANCE COMPANY

SECONDARY INSURANCE COMPANY

INSURANCE COMPANY PHONE NUMBER/CONTACT PERSON

INSURANCE COMPANY PHONE NUMBER/CONTACT PERSON

INSURANCE COMPANY ADDRESS

INSURANCE COMPANY ADDRESS

POLICY HOLDER/RELATIONSHIP TO PATIENT

POLICY HOLDER/RELATIONSHIP TO PATIENT

FINANCIAL DISCLOSURE I certify that the information given by me in applying for payment under my insurance contract (including Title XVIII of the Social Security Act) is correct. I authorize release to my insurance carrier, employer and referring physician any information needed including diagnosis and records of any treatment or examination rendered to me to process this claim. I request that payment of authorized benefits be made on my behalf. I assign my insurance benefits payable to Spine, Orthopedics and Rehabilitation and authorize Spine, Orthopedics and Rehabilitation to submit a claim to my insurance carrier, including Medicare, for payment. I understand that charges not covered by my insurance company will be my responsibility and that I will receive monthly statements reflecting my account balance and that the FINAL PAYMENT of this account remains my responsibility. A late payment will be charged monthly interest of 3%. I understand that if I do not have insurance coverage that I am responsible for all charges for office visits and procedures performed at Spine, Orthopedic and Rehabilitation in full before any services are rendered to me. This authorization and assignment is to be a continuing one, remaining in force until revoked in writing by the undersigned for services rendered. I understand that it is the office policy of Spine, Orthopedics and Rehabilitation that every patient on chronic opiate therapy are subject to a urine toxicology screening. I consent to a random urine toxicology screening at the request of my physician. I understand that if my insurance company does not cover the cost of this testing that I am responsible for payment in full for these services. A $35.00 no show fee will apply if 24 hour cancellation is not given. Date: _________________________ Signature: ________________________________________ Witness: ______________________________________

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake May, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

INFORMATION UPDATE PATIENT NAME:______________________________________________ DATE:__________________________________________ HAVE YOU HAD ANY NEW INJURIES/ACCIDENTS SINCE YOUR LAST OFFICE VISIT? YES NO IF YES, PLEASE EXPLAIN: _________________________________________________________________________________________________________________

ARE THESE INJURIES RELATED TO AN ON THE JOB INJURY OR AUTO ACCIDENT? YES NO IF YES, PLEASE EXPLAIN: _________________________________________________________________________________________________________________ HAVE YOU HAD ANY SURGERIES OR TREATMENT SINCE YOUR LAST VISIT? YES NO IF YES, PLEASE EXPLAIN: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ PLEASE LIST YOUR CURRENT MEDICATIONS: _________________________________________________________________________________________________________________ DO YOU HAVE ANY KNOWN DRUG ALLERGIES/REACTIONS? YES NO IF YES, PLEASE EXPLAIN: _________________________________________________________________________________________________________________ DO YOU HAVE A PRIMARY CARE PHYSICIAN?

YES

NO

YES

NO

WHAT IS YOUR PRIMARY CARE PHYSICIAN’S NAME?______________________________________________________________ DO YOU NEED A REFERRAL TO A PRIMARY CARE PHYSICIAN?

WHAT IS THE MAIN REASON FOR YOUR OFFICE VISIT TODAY? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake May, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

PATIENT NAME: _______________________________ DATE: _____________________________ I consent to any and all medical treatments and diagnostic examinations administered at or offered in association with the operation of the SOAR Medical Center which may be deemed advisable by my physician or healthcare provider to diagnose and/or treat me during the period I am accepted as a patient of SOAR Medical Center. CONSENT TO TREAT OTHERS I, ______________________________________, consent to any and all medical treatments and diagnostic examinations administered at or offered in association with the operation of the SOAR Medical Center which may be deemed advisable by my physician or healthcare provider to diagnose and/or treat, ______________________________________, during the period that he/she is accepted as a patient of SOAR Medical Center. I certify that the information given by me in applying for payment under my insurance contract (including Title XVIII of the Social Security Act) is correct. I authorize release to my insurance carrier, employer and referring physician any information needed including diagnosis and records of any treatment or examination rendered to me to process this claim. I request that payment of authorized benefits be made on my behalf. I assign my insurance benefits payable to Spine, Orthopedics and Rehabilitation and authorize Spine, Orthopedics and Rehabilitation to submit a claim to my insurance carrier, including Medicare, for payment. I understand that charges not covered by my insurance company will be my responsibility and that I will receive monthly statements reflecting my account balance and that the FINAL PAYMENT of this account remains my responsibility. A late payment will be charged monthly interest of 3%. I understand that if I do not have insurance coverage that I am responsible for all charges for office visits and procedures performed at Spine, Orthopedic and Rehabilitation in full before any services are rendered to me. This authorization and assignment is to be a continuing one, remaining in force until revoked in writing by the undersigned for services rendered. I understand that it is the office policy of Spine, Orthopedics and Rehabilitation that every patient on chronic opiate therapy are subject to a urine toxicology screening. I consent to a random urine toxicology screening at the request of my physician. I understand that if my insurance company does not cover the cost of this testing that I am responsible for payment in full for these services. A $35.00 no show fee will apply if 24 hour cancellation is not given. ________________________________________ Patient Name / Authorized Guardian Name

___________________________________________ Signature of Patient or Authorized Guardian

____________________________________ Witness Signature

___________________________________________ Date

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake May, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

HIPAA CONTACT INFORMATION FORM In order to assist you in receiving your health information from SOAR, please complete this form. *** Initial one: _____ (initial) SOAR is permitted to share any and all medical information with the individuals and contact information listed below, including test results, sensitive information as stipulated by the State of Florida, and information disclosed during office visits. _____ (initial) SOAR is permitted to share any and all medical information with the individuals and contact information listed below, including test results, sensitive information as stipulated by the State of Florida, and information disclosed during office visits ** EXCEPT: _________________________________________ _________________________________________________________________________________________ Persons authorized to receive my medical information (full name, relationship and phone number):

NAME

RELATIONSHIP

PHONE NUMBER(S)

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ***PHARMACY: ____________________________________________________________________________ ***PRIMARY CARE PHYSICIAN: ________________________________________________________________ You may notify me with the test results, appointment reminders and other information regarding my health information as follows: _____ Message on answering machine – (Phone number:) __________________________________________ _____ Message on work voice mail – (Phone number:) _____________________________________________ _____ Message on cell phone – (Phone number:) _________________________________________________ _____ Message on E-Mail: ____________________________________________________________________ _____ Message on Fax (Fax number:) ___________________________________________________________ ** I understand and direct that this authorization will remain in effect until it is revoked by me in writing. ________________________________________ Patient – Print Name

______________________________________ Signature

Date of Birth: _____________________________

Expiration: ____________________________

*** This authorization is not valid for the request of printed copies of your medical records. You and only you (or your legal personal representative) must sign a Health Information Release Form to obtain copies of your medical records. 389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake May, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

PROTECTED HEALTH INFORMATION RELEASE AND REQUEST OF MEDICAL RECORDS PATIENT NAME: _________________________________________________ DATE OF BIRTH: ________________ PATIENT NAME AND ADDRESS: ______________________________________________ APT. ________________ _____________________________________________________________________________________________

MEDICAL RECORDS REQUEST The undersigned authorizes the physician(s) listed below to release my medical and/or financial records to Brian C. Dowdell, M.D. Records should include any Federal and State protected information under Florida Statute 396.459 (9) Psychiatric information, Florida Statute 397.053 and Florida Statute 396.112 Drug and/or Alcohol Abuse information and Florida Statute 381.609 (2) HIV tests (AIDS and related conditions). ________________________________________________________________ Expiration Duration: _________________________

________________________________________________________________ ________________________________________________________________ ________________________________________________________________

MEDICAL RECORDS RELEASE The undersigned authorizes Brian C. Dowdell, M.D. to release my medical and/or financial records to the physician(s) listed below. Records should include any Federal and State protected information under Florida Statute 396.459 (9) Psychiatric information, Florida Statute 397.053 and Florida Statute 396.112 Drug and/or Alcohol Abuse information and Florida Statute 381.609 (2) HIV tests results (AIDS and related conditions). Expiration Duration: _________________________

________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

REQUEST TO INSPECT AND COPY PROTECTED HEALTH INFORMATION – FEES I understand and agree that I am financially responsible for the following fees associated with my request: copying charges, including costs of supplies and labor, and postage related to the production of my information. I understand that the charge for this service is $1.00 per page for the first 25 pages and $.25 for each additional page thereafter. Once your request has been completed and the fee has been paid, Spine, Orthopedics and Rehabilitation will respond within 30 days for the information that is stored onsite and within 60 days for information that is stored offsite. The practice may request one 30-day extension, if we provide you with a written notice of the reason for the delay. If you are requesting to inspect your records, an appointment time will be scheduled to allow 15 minutes for you to review your records. ____________________________________ ____________________________________ PATIENT SIGNATURE WITNESS SIGNATURE *** If the patient is a minor, a guardian consent must be obtained and witness below:

_______________ DATE

____________________________________ OTHER/GUARDIAN SIGNATURE

_______________

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

____________________________________ WITNESS SIGNATURE DATE 1315 S. International Pkwy, Suite 1111 Lake May, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

ADVANCE DIRECTIVES In order to be in compliance with the Self-Determination Act (PSDA) and the State law and rules regarding advance directive, the Facility requires each patient prior to scheduled procedures to read and acknowledge the Facility position on advance directives. Advance Directives are statements that indicate the type of medical treatment wanted or not wanted in the event an individual is unable to make those determinations and who is authorized to make those decisions. The advance directives are made and witnessed prior to serious illness or injury. There are many types of advance directives, but the two most common forms are: Living Wills. These generally state the type of medical care individual wants or does not want if he/she becomes unable to make his/her own decisions. Durable Power of Attorney for Health Care. This is a signed, dated and witnessed paper a i g a other perso as a i dividual’s age t or pro to ake edical decisio for that individual if he/she should become unable to make his/her decisions. In the event of a medical emergency or other life threatening situation, resuscitation will be instituted in every instance and patients will be transferred to a higher level of care. Any previously formulated advance directives will not be honored at the Facility. If for any reason you disagree with this policy, please discuss your concerns with your physician before arriving for your scheduling procedure. I have read and acknowledge that the Facility does not honor Advance Directives. Patient Signature: __________________________________________

Date: _____________

Witness Signature: __________________________________________

Date: _____________

If the patient is unable to sign or is a minor, please sign: Relative/Guardia ’s Sig ature: ________________________________

Date: _____________

Witness Signature: __________________________________________

Date: _____________

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake May, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

Name: ___________________________________________________________ Date: _____________________ Please indicate the location of your pain on these drawings. You may use the symbols provided, by placing them on the diagrams.

SPINAL PAIN PATIENT QUESTIONNAIRE

Pain

Symbol

Pins & Needles

oooooooooooooooo oooooooooooooooo

Burning

**************** ****************

Numbness

============== ==============

Stabbing

/////////////////////////// //////////////////////////

Aching

-------------------------------------------

For Internal Use Only:

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________________________ _______________________________________________________________________________________________

Page 1 of 5 389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

Name: ___________________________________________________________ Date: _____________________ Please list all physicians and/or chiropractors you have consulted for your present condition including is your PCP. _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ PRIMARY CARE PHYSICIAN: ____________________________________________________________________________________ List all previous surgeries: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Any drug allergies:

YES

NO

IF YES, which ones _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Allergic to anesthetics?

YES

NO

Allergic to iodine, shellfish or IVP dye?

YES

NO

Please circle any of the following problems that you have experienced: Diabetes

Seizures

Fevers or chills

Heart Disease

Loss of Consciousness

Hepatitis

High Blood Pressure

Unexplained Weight Loss

Asthma

Cancer

Night Sweats

Stomach Ulcers

Heart Attack

Tuberculosis

Dizziness

Fainting

Difficulty with Bowel

Kidney Stones

Difficulty swallowing

Movements

Swelling of toes or finger joints

Change in ability to pass urine

Prostate Disease

Headaches

Bleeding Disorders

Kidney Infections

Thyroid Disease

Other __________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Please list all medications which you are currently taking: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Page 2 of 5 389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

www.soarflorida.com

Name: ___________________________________________________________ Date: _____________________ Do you have any family history of: Diabetes

Seizures

Fevers or chills

Heart Disease

Loss of Consciousness

Hepatitis

High Blood Pressure

Unexplained Weight Loss

Asthma

Cancer

Night Sweats

Stomach Ulcers

Heart Attack

Tuberculosis

Dizziness

Fainting

Difficulty with Bowel

Kidney Stones

Difficulty swallowing joints

Movements

Swelling of toes or finger

Change in ability to pass urine

Prostate Disease

Headaches

Bleeding Disorders

Kidney Infections

Thyroid Disease

Other: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Are you currently working?

YES

NO

Occupation ______________________________________________________

If no, which activities at work can’t you do? ___________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Date last worked? _________________________________________________________________________________________ Do you smoke cigarettes?

YES

NO

How much per day? _______________

Do you drink alcohol?

YES

NO

How much? ______________________

Do you drink to control your pain?

YES

NO

For how long have you been with your current employer: ____________________________________________________ Did your injury occur at work?

YES

NO

UNSURE

Date of injury: ___________________________________________________________________________________________________

Which activities (leisure, sports hobbies) do you hope to return? ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ What is your age: ____________________

Hand Dominance

RIGHT

LEFT

BOTH

Date of onset of present pain: _____________________________________________________________________________________

Page 3 of 5 389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

www.soarflorida.com

Name: ___________________________________________________________ Date: _____________________ Cause of current pain (fall, motor vehicle accident, etc.): _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ What percentage of your pain is:

back pain ____________ leg pain ____________ neck pain ____________ arm pain ____________

Which is the most limiting: ______________________________________________________________________ ______________________________________________________________________ Indicate how your work/leisure activity is limited: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ What makes your pain better (please circle): laying

sitting

standing

walking

driving

sports

Other __________________________________________________________ ___________________________________________________________ What makes your pain worse (please circle):

laying

sitting

standing

walking

driving

sports

other _____________________________________________________ _____________________________________________________ Which one is the worst (if any): __________________________________________________________________________ __________________________________________________________________________ Please grade your pain:

(no pain)

Does your pain keep you up all night?

0

1

2

3

4

YES

Are you experiencing any weakness in your (please circle):

5

6

7

8

9

10

(worst imaginable)

NO arm (right or left)

leg (right or left)

What medications have you tried in the past for your spinal pain? _____________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Which medications are you currently taking for your spinal pain? _____________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Pharmacy: Name, Location and Phone Number:____________________________________________________________ ______________________________________________________________________________________________________ Page 4 of 5 389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

Name: ___________________________________________________________ Date: _____________________ What previous non-surgical treatments have you had (physical therapy, chiropractic, acupuncture, epidurals, etc.)? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ How did you respond to this treatment? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ What is the most recent treatment you have undergone? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Have you undergone surgery in the past?

YES

NO

When was the surgery performed? ________________________________________________________________________ What were your symptoms prior to surgery? _______________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Did you improve after your most recent surgery?

YES

NO

If Yes, which symptoms improved? ________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ For how long were you better after your last surgery? _______________________________________________________________________________________________ _______________________________________________________________________________________________ If No, did your symptoms worsen post operatively? Have you had any:

YES

NO

Date

Location

Spine Xrays

_____________

_____________________________________

EMG

_____________

_____________________________________

MRI/CT Scan

_____________

_____________________________________

Page 5 of 5 389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

INFORMED CONSENT FOR OPIOID TREATMENT FOR NON-CANCER/CANCER PAIN

The purpose of this agreement is to give you information about the medications you will be taking for pain management and to assure that you and your physician/health care provider comply with all state and federal regulations concerning the prescribing of controlled substances. A trial of opioid therapy can be considered for moderate to severe pain with the intent of reducing pain and increasing function. The ph si ia ’s goal is fo ou to have the best quality of life possible given the reality of your clinical condition. The success of treatment depends on mutual trust and honesty in the physician/patient relationship and full agreement and understanding of the risks and benefits of using opioids to treat pain. I have agreed to use opioids (morphine-like drugs) as part of my treatment for chronic pain. I understand that these drugs can be very useful, but have a high potential for misuse and are therefore closely controlled by the local, state, and federal government. Because my physician/ health care provider is prescribing such medication to help manage my pain, I understand the following risks and benefits: 1.

I agree to take the medication only as prescribed. a.

I understand that increasing my dose without the close supervision of my physician could lead to drug overdose causing severe sedation and respiratory depression and death.

b.

I understand that decreasing or stopping my medication without the close supervision of my physician can lead to withdrawal. Withdrawal symptoms can include yawning, sweating, watery eyes, runny nose, anxiety, tremors, aching muscles, hot and cold flashes, goose flesh , a do i al a ps, a d dia hea. These s pto s a o u 2448 hours after the last dose and can last up to 3 weeks.

2.

There are side effects with opioid therapy, which may include but are not limited to skin rash, constipation, sexual dysfunction, sleeping abnormalities, hormonal imbalances/deficiencies, sweating, edema, sedation, or the possibility of impaired cognitive (mental status) and/or motor ability. I understand that taking opioids may impair my ability to drive or operate heavy machinery. Overuse of opioids can cause decreased respiration (breathing) and even respiratory failure or cardiac arrest.

3.

The opioid should never e give o sold to othe s e ause it and is against the law.

4.

If I have a history of alcohol or drug misuse/addiction, I must notify the physician of such history since the treatment with opioids for pain may increase the possibility of relapse.

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake May, FL 32746

a e da ge that pe so ’s health

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

5.

I should not use any illicit substances, such as cocaine, marijuana, etc. while taking these medications. This can lead to serious side effects including death.

6.

Medications like Valium or Ativan; sedatives such as Soma, Xanax, Fiorinal; antihistamines like Benadryl; herbal remedies, alcohol, and cough syrup containing alcohol, codeine, or hydrocodone can interact with opioids and produce serious side effects.

7.

While physical dependence is to be expected after long-term use of opioids, signs of addiction, abuse, or misuse shall prompt the need for substance dependence treatment as well as weaning and detoxification from the opioids. a.

Physical dependence is common to many drugs such as blood pressure medications, anti-seizure medications, and opioids. It results in biochemical changes such that abruptly stopping these drugs will cause a withdrawal response. It should be noted that physical dependence does not equal addiction. One can be dependent on insulin to treat diabetes or dependent on prednisone (steroids) to treat asthma, but one is not addicted to the insulin or prednisone.

b.

Addiction is a primary, chronic neurobiologic disease with genetic, psychosocial and environmental factors influencing its development and manifestation. It is characterized by behavior that includes one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and cravings. This means the d ug de eases o e’s ualit of life. If the patie t e hi its su h ehavio , the d ug will be tapered and such a patient is not a candidate for an opioid trial. He/she will be referred to an addiction medicine specialist.

c.

Tolerance means a state of adaptation in which exposure to the drug induces changes that esult i a lesse i g of o e o o e of the d ug’s effe ts ove ti e. The dose of the opioid may have to be titrated up or down to a dose that produces maximum function and a realistic de ease of the patie t’s pai .

I, ______________________________________________ have read the above information or it has been read to me and all my questions regarding the treatment of pain with opioids have been answered to my satisfaction. I hereby give my consent to participate in the opioid medication therapy and acknowledge receipt of this document. Patie t’s “ig atu e_______________________________________ Date_____________________ Gua dia ’s “ig atu e _____________________________________ Date _____________________ Wit ess’s “ig atu e_______________________________________ Date________________________

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake May, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

AGREEMENT FOR OPIOID TREATMENT FOR NON-CANCER/CANCER PAIN The purpose of this agreement is to give you information about the medications you will be taking for pain management and to assure that you and your physician/health care provider comply with all state and federal regulations concerning the prescribing of controlled substances. A trial of opioid therapy can be considered for oderate to se ere pai ith the i te t of redu i g pai a d i reasi g fu tio . The ph si ia ’s goal is for ou to have the best quality of life possible given the reality of your clinical condition. The success of treatment depends on mutual trust and honesty in the physician/patient relationship and full agreement and understanding of the risks and benefits of using opioid to treat pain. I have agreed to use opioid (morphine-like drugs) as part of my treatment for chronic pain. I understand that these drugs can be very useful, but have a high potential for misuse and are therefore closely controlled by the local, state, and federal government. Because my physician/health care provider is prescribing such medication to help manage my pain, I agree to the following conditions: 1.

I am responsible for my pain medications. I agree to take the medication only as prescribed.

2.

I will not request or accept controlled substance medication from any other physician or individual while I am receiving such medication from my physician/health care provider at S.O.A.R.

3.

It is my responsibility to notify my physician/health care provider for any side effects that continue or are severe (i.e., sedation, confusion). I am also responsible for notifying my pain physician immediately if I need to visit another physician or need to visit an emergency room due to pain, or if I become pregnant.

4.

I understand that the opioid medication is strictly for my own use. The opioid should never be given or sold to others e ause it a e da ger that perso ’s health a d is against the law.

5.

I should inform my physician of all medications I am taking, including herbal remedies or medications like Valium, Ativan, Soma, Xanax, Fiorinal, Benadryl, alcohol, or cough syrup containing alcohol, codeine, or hydrocodone, etc. I understand these products can interact with opioids and produce serious side effects.

6.

During the time that my dose is being adjusted, I will be expected to return to the clinic as instructed by my clinic physician. After I have been placed on a stable dose, I will return to the pain clinic for a medical evaluation at least once every month per Florida guidelines for a face-to-face evaluation to review the ongoing need for opioid prescriptions.

7.

I understand that opioid prescriptions will not be mailed or post-dated. If I am unable to obtain my prescriptions monthly, I will be responsible for finding a local physician who can take over the writing of my prescriptions with consultations from my pain physician.

8.

Any evidence of drug hoarding, acquisition of any opioid medication or adjunctive analgesia from other physicians (which includes emergency rooms), uncontrolled dose escalation or reduction, loss of prescriptions, or failure to follow the agreement may result in termination of the doctor/patient relationship. I understand that in the event my physician discovers that I am selling my pain edi atio s or o tai i g pai edi atio fro other pro iders k o as do tor shoppi g , the physician will notify the police as required by Florida statutes.

9.

I will communicate fully with my physician to the best of my ability at the initial and all follow-up visits my pain level and functional activity along with any side effects of the medications. This information allows my physician to adjust my treatment plan accordingly.

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

10. I will not use any illicit substances, such as cocaine, marijuana, etc. while taking these medications. This may result in a change in my treatment plan, including safe discontinuation of my opioid medications he appli a le u der the ph si ia ’s dire tio or a referral to a deto ifi atio e ter a d/or complete termination of the doctor/patient relationship. 11. The use of alcohol together with opioid medications is contraindicated. 12. I am responsible for my opioid prescriptions. I understand that: a.

Refill prescriptions can be written for a maximum of one-month supply and will be filled at the same pharmacy.

b.

It is my responsibility to schedule appointment to the next opioid refill before I leave the clinic or within 3 days of the last clinic visit.

c.

I am responsible for keeping my pain medications in a safe and secure place, such as a locked cabinet or safe. I am expected to protect my medications from loss or theft. I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. If my medication is stolen, I will report this to my local police department and obtain a stolen item report. I will then report the stolen medication to my physician. If my medications are lost, misplaced, or stolen my physician may choose not to replace the medications or to taper and discontinue the medications.

d.

Refills ill ot e ade as a ru out to orro .

e.

Refills can only be filled by a pharmacy in the State of Florida, even if I am a resident of another state.

f.

Prescriptions for pain medicine or any other prescriptions will be done only during an office visit or during regular office hours. No refills of any medications will be done during the evening or on weekends.

g.

You must bring back all opioid medications and adjunctive medications prescribed by your physician in the original containers/bottles at every visit.

h.

Prescriptions will not be written in advance due to vacations, meetings, or other commitments.

i.

If an appointment for a prescription refill is missed, another appointment will be made as soon as possible. Immediate or emergency appointments will not be granted.

j.

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, su h as o Frida after oo

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appoi t e ts for opioid refills ill e gra ted.

13. If it appears to the physician/health care provider that there is no improvement in my daily function or quality of life from the controlled substance, my opioids may be discontinued. I will gradually taper my medication as prescribed by the physician. 14. If I have a history of alcohol or drug misuse/addiction, I must notify the physician of such history since the treatment with opioids for pain may increase the possibility of relapse. A history of addiction does not, in most instances, disqualify one for opioid treatment of pain, but starting or continuing a program for recovery is a necessity.

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

www.soarflorida.com

308 South Harbor City Boulevard, Suite A, Melbourne, FL 32901 Ph: (321) 733-0064 Fax: (321) 733-7970 Toll-Free: 866-734-SOAR (7627)

15. I will be seen on a regular basis and given prescriptions for enough medication to last from appointment to appointment, and sometimes two to three days extra if the prescription ends on a weekend or holiday. This extra medication is not to be used without the explicit permission of the prescribing physician unless an emergency requires your appointment to be deferred one or two days. 16. I agree and understand that my physician reserves the right to perform random or unannounced urine drug testing. If requested to provide a urine sample, I agree to cooperate. If I decide not to provide a urine sample, I understand that my doctor may change my treatment plan, including safe discontinuation of my opioid medications when applicable or complete termination of the doctor/patient relationship. The presence of a non-prescribed drug(s) or illicit drug(s) in the urine can be grounds for termination of the doctor/patient relationship. Urine drug testing is not forensic testing, but is done for my benefit as a diagnostic tool and in accordance with certain legal and regulatory materials on the use of controlled substances to treat pain. 17. I agree to allow my physician/health care provider to contact any health care professional, family member, pharmacy, legal authority, or regulatory agency to obtain or provide information about your care or actions if the physician feels it is necessary. 18. I agree to a family conference or a conference with a close friend or significant other if the physician feels it is necessary. 19. I understand that non-compliance with the above conditions may result in a re-evaluation of my treatment plan and discontinuation of opioid therapy. I may be gradually taken off these medications, or even discharged from the clinic. I, _____________________________________, have read the above information or it has been read to me and all my questions regarding the treatment of pain with opioids have been answered to my satisfaction. I hereby give my consent to participate in the opioid medication therapy and acknowledge receipt of this document. Patie t’s “ig ature: _________________________________________

Date: ___________________

Guardia ’s “ig ature: _______________________________________

Date: ___________________

Wit ess’s “ig ature: _________________________________________ Date: ___________________ _____________________________________________________________________________________________

*** PATIENT WAIVER FOR CONTROLLED SUBSTANCES *** I, ______________________________, agree NOT to receive any controlled substances such as opioids from SOAR and its providers. I WILL notify SOAR and its providers of my wish to receive controlled substances such as opioids changes. _______________________________________ Patient / Authorized Guardian Signature

_______________________________________ Witness

______________________________________ Date

389 Commerce Pkwy, Suite 120 Rockledge, FL 32955

1315 S. International Pkwy, Suite 1111 Lake Mary, FL 32746

12301 Lake Underhill Road, Suite 121 Orlando, FL 32828

Patient Responsibilities As a patient, you are responsible for: ■ providing accurate and complete information about present physical complaints, past illnesses, hospitalizations, medications and other matters relating to your health; ■ reporting unexpected changes in your condition to your doctors and nurses; ■ reporting your pain and working with the staff to manage your pain; ■ asking questions if you do not understand your treatment or what is expected of you; ■ following the treatment plan recommended by the clinic staff and/or physicians; ■ your actions if you refuse treatment or do not follow the healthcare provider’s instructions; ■ thoughtful consideration of your wishes about end-of-life care and for communicating those wishes through advance directives; ■ providing accurate insurance and payment information to the clinic and physicians at the time of registration or service; ■ complying with the clinic’s rules and regulations affecting patient care and conduct; ■ ensuring that the financial obligations of your healthcare are fulfilled as promptly as possible; ■ being considerate of the rights of other patients and clinic personnel and for assisting in the control of noise and the number of visitors; ■ being respectful of the property of other people and the clinic; ■ keeping appointments and, when unable to do so for any reason, notifying your healthcare provider or doctor’s office; ■ safeguarding your belongings (valuables should be sent home or kept with your caregiver during a procedure.

References: ■ ■ ■

Contact the Florida Department of Heath 850-245-4444 [email protected] Florida Department of Health 4052 Bald Cypress Way Tallahassee, FL 32399

Spine Orthopedics and Rehabilitation (S.O.A.R.) 308 South Harbor City Boulevard, Suite A Melbourne, FL 32901

Patient Rights

Ph: (321) 733-0064 Fax: (321) 733-7970

www.soarflorida.com

And Responsibilities Florida Statutes 381.026

PaFFtient Rights and Responsibilities ©SOAR MEDICAL

SOAR Medical believes it’s important for you to take an active part in your healthcare. That’s why we’ve provided you with this list of Patient Rights and Responsibilities. By becoming familiar with these points, you can better participate in your care and act as a vital part of the healthcare team. If you have any questions or concerns about your rights and responsibilities, please call the number listed on the back. Patient Rights As a patient you have the right to: be treated with courtesy and respect for your cultural, psychosocial, spiritual and personal values, beliefs and preferences, as well as with appreciation of individual dignity and protection of privacy and informational confidentiality within the law; ■

■ a prompt and reasonable response to questions and requests;

have a family member or representative of your choice and your own physician notified promptly if your condition has changed or you get admitted to the hospital;

■

know who is providing medical services and who is responsible for your care;

■

know what patient support services are available, including access to a phone for private telephone conversations, interpreters, translators and resources for the disabled; ■

■ impartial access to medical treatment or accommodation regardless of race, national origin, religion, physical handicaps or sources of payment;

treatment for any emergency medical condition that will get worse from failure to provide treatment;

■

rights or safety, or is medically or therapeutically contraindicated;

for or alternative to a transfer of your care (transfer must be acceptable to the other facility);

■

appropriate assessment and management of your pain, and to be involved in decisions about managing pain;

■

be free from restraints or seclusion unless necessary for your safety or to prevent injury to others.

Justified Clinical Restrictions

be informed by your healthcare provider of continuing healthcare requirements after your discharge;

■

Means any clinically necessary or reasonable restriction or limitation imposed by the clinic on a patient’s visitation rights which restrictions or limitations is necessary to provide safe care to patients. A Justified Clinical Restriction may include, but not limited to one or more of the following: A court order limiting or restraining contact; behavior presenting a direct risk or threat to the patient, clinic staff or others in the immediate environment; behavior disrupting to the functioning of the patient care; reasonable limitations on the number of visitors at any one time; patient’s risk of infection by the visitors; and visitor’s risk of infection by the patient; extraordinary protections because of a pandemic or infectious disease outbreak; patient’s need for privacy or rest; the need for privacy or rest by another individual in the clinic undergoing a clinical intervention or procedure and the treating healthcare provider believes it is in the patient’s best interest to limit visitation during the clinical intervention or procedure.

initiate or amend an advance healthcare directive;

■

participate in decisions about your care at the end of life with competent attention to your physical, psychosocial, spiritual and cultural needs; ■

refuse any treatment, except as otherwise provided by law;

■

■ know if medical treatment is for a clinical trial and to give your informed consent or refusal to participate in experimental research;

information about accessing protective services if you feel you are in physical danger, or have been abused, neglected or exploited by anyone, including family members, visitors, other patients, staff, students or volunteers. Contact the Administrator at SOAR Medical (321) 733-0064; ■

receive, upon request, prior to treatment, a reasonable estimate of charges for medical care;

■

receive, upon request, information and counseling on the availability of known financial resources for your care;

■

■

■ know, upon request, in advance of treatment, whether the healthcare provider or facility accepts the Medicare assignment rate if you are eligible for Medicare;

receive, upon request, a copy of a reasonably clear and understandable itemized bill and to have the charges explained;

■

know what rules and regulations apply to your conduct;

■

be given information concerning the diagnosis, prognosis, planned course of treatment, benefits, risks and alternatives presented in a language and manner that you can understand; ■ have your family involved in decision making with permission from you or your surrogate. Patient has the right to withdraw permission of said member (s); at any time. ■

the presence of support individuals of your choice, unless the individuals’ presence infringes on others’

■

access to the Ethics Committee and the option to participate in the process to resolve ethical issues. Contact the Administrator at SOAR Medical (321) 733-0064;

■

expect reasonable safety insofar as SOAR Medical’s practices and environment permit;

■

consult with a specialist, at your request and expense;

■

■

receive a complete explanation about the need

■ ■ ■

Express a complaint or grievance regarding safety, quality of care or any violation of your rights as stated in Florida law, through the grievance procedure at this SOAR Medical facility, or to the appropriate state licensing agency, Florida Department of Health. SOAR Medical is committed to addressing your concerns about patient care and safety, and requests that you contact the Administrator at SOAR Medical at (321) 733-0064; or call or write to: Contact the Florida Department of Heath 850-245-4444 [email protected] Florida Department of Health 4052 Bald Cypress Way Tallahassee, FL 32399