New Patient Online Form Which doctor are you seeing? Which doctor are you seeing? Please mark the circle next to your doctor Dr. Grishow Dr. Brown Dr. Davanzo Dr. Murphy Dr. Babbitt Appointment Date Patient Information Please Complete Fully Legal First Name Legal Last Name Middle Initial Maiden Name Street Address City State Zip Code Last Four Digits of Your Social Security Number Birth Date Age Gender Gender Female Male Marital Status Marital Status Single Married Divorced Separated Widowed Best Contact Phone Number Email Address Emergency Contact Emergency Contact Relationship To You Emergency Contact Phone Number Drivers License Number Drivers License Photo If you would like, please upload a photo of your drivers license.File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, tiff, tif, webp, avif. Max. file size: 1 MB Employer Occupation Pharmacy Name Pharmacy Phone Number Primary Care/Family Physician Primary Care/Family Physician Phone Number Referring Physician (if different) Referring Physician (if different) Phone Number Insurance Information **It is the patient's responsibility to determine network coverage/benefits at the time of service** Please bring both your insurance card and driver's license to your appointment. Do you have insurance? Do you have insurance? Yes No Primary Insurance Name Primary Insurance Number Primary Insurance Group Number Primary Insurance Card Photo If you would like, please upload a photo of your insurance card.File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, tiff, tif, webp, avif. Max. file size: 1 MB Secondary Insurance Tricare Insurance Members Only Sponsor Name Birthdate SS# Relevant Medical History Have you had any of the following imaging in the past year? MRI MRI Yes No If yes, on what body part and at which facility? CT/CAT Scan CT/CAT Scan Yes No If yes, on what body part and at which facility? X-Ray X-Ray Yes No If yes, on what body part and at which facility? Ultrasound Ultrasound Yes No If yes, on what body part and at which facility? EKG/ECG EKG/ECG Yes No If yes, on what body part and at which facility? HIDA Scan HIDA Scan Yes No If yes, on what body part and at which facility? Mammogram Mammogram Yes No If yes, on what body part and at which facility? If you had any other scans, which scan, on what body part and at which facility? When was the last time you had bloodwork? Where? Have you ever had a blood transfusion? Have you ever had a blood transfusion? Yes No If yes, when? Have you had any of the following procedures in the past 5 years? EGD EGD Yes No If yes, which doctor and at which facility? Upper GI Upper GI Yes No If yes, which doctor and at which facility? Colonoscopy Colonoscopy Yes No If yes, which doctor and at which facility? Have you ever had a hernia repair surgery before? Have you ever had a hernia repair surgery before? Yes No If yes, which hospital? What year? Surgeon's name? Have you been to the Emergency Room in the past year? Have you been to the Emergency Room in the past year? Yes No If yes, where? What was the reason? Patient Acknowledgement of Receipt of the Notice of Privacy Practices, Medical Records Release, Approval of Contact and Financial Responsibility I, the undersigned, authorize the release of medical information to my primary care or referring physician and to consultants if necessary, including work release forms. By listing authorized parties and signing this form, I am acknowledging receipt of the Notice of Privacy Practices of Westerville Surgical Associates. Any additional persons/ groups not listed in those which you wish to receive medical information, will require additional authorization by the patient. I may revoke this authorization in writing at any time, except for information, which has already been released in accordance with this authorization prior to my revocation. Westerville Surgical Associates reserves the right to change the privacy practices that are described in the Notice of Privacy Practices and I may contact the office to obtain a revised Notice of Privacy Practices. *Please indicate ALL PERSONS/GROUPS YOU WISH TO RELEASE your records to: I authorize my healthcare provider and/or any entity authorized by my healthcare provider, including those using automated dialing systems, automated messages, email, text messaging and/or other electronic communication to contact me or any contacts provided by me, insurance, or other healthcare providers, for any reason by using any telephone number, email address and/or mailing address associated with my account. I, the undersigned, certify that I (or my dependent) have health insurance or Medicare/Medicaid and assign directly to Westerville Surgical Associates all of these benefits, if any, otherwise payable to me for services rendered. I understand that it is my responsibility to ensure that I have insurance coverage with my provider and that I am financially responsible for all in or out-of-network services provided by Westerville Surgical Associates. I am responsible for providing accurate and up-to-date insurance and identifying information. I understand that I am financially responsible for any deductibles, coinsurance, co-pays, non-covered services, and anything considered “not medically necessary” by my insurance company, or charges that are not paid by my specific insurance company. I understand that if I do not have health insurance I am financially responsible for any and all charges for services rendered by Westerville Surgical Associates. If I am unable to provide proper identification or cannot present a physical insurance card and proof of insurance at the time of service, I will be treated as if I do not have health insurance and am financially responsible for any and all charges for services rendered by Westerville Surgical Associates. I understand that all copays and fees are due at the time of service. I certify that the information provided by me for payment and services is correct. I authorize Westerville Surgical Associates to release any necessary information needed to determine liability for payment and to obtain reimbursement on any claim. I acknowledge that upon signing, I have been made aware of Westerville Surgical Associates' cancellation policy. Under this policy, after two instances of canceling less than 48 hours prior, or not arriving to my office visit I will be charged $25. I also acknowledge that I will be charged $150 for canceling less than 48 hours prior or not arriving to any anesthetic procedure. These charges must be paid in full before I am able to reschedule an appointment or anesthetic procedure. Signature of Patient or Responsible Party Be sure to save your signature. SaveClear Full Name Today's Date Health History Date of Last Physical Examination What is your reason for today's visit? Is today's visit urgent? Is today's visit urgent? Yes No Please Explain. Symptoms Check symptoms you currently have or have had in the past year. Constitution Constitution Activity Change Chills Fatigue Fever Poor Appetite Excessive Hunger Excessive Thirst Sweats Unexpected Weight Change None Gastrointestinal Gastrointestinal Abdominal Pain Bloating Blood in Stool Constipation Diarrhea Gas Idigestion Nausea Rectal Bleeding Rectal Pain Vomiting None Respiratory Respiratory Apnea Chest Tightness Persistent Cough Shortness of Breath None Head, Ears, Nose and Throat Head, Ears, Nose and Throat Bleeding Gums Hoarseness Nosebleeds Trouble Swallowing None Genitourinary Genitourinary Difficulty Urinating Flank Pain Frequency Genital Sore Hematuria Painful Urination Urgency None Cardiovascular Cardiovascular Chest Pain High Blood Pressure Irregular Heart Beat Low Blood Pressure Poor Circulation Rapid Heart Beat Swelling of Ankles Varicose Veins None Eyes Eyes Blurred Vision Yellowing of Eyes None Muscular Muscular Back Pain Muscle Pain None Skin Skin Pallor Rash Wound Yellowing of Skin None Hematologic Hematologic Bruises/Bleeds Easily Swollen Lymph Nodes None Psychiatric Psychiatric Agitation Behavior Problem Confusion Nervous/Anxious Sleep Disturbance Suicidal Ideas/Attempts None Men ONLY Men ONLY Breast Lump Penis Discharge Penile Pain Testicular Pain Testicular Mass None Women ONLY Women ONLY Breast Lump Nipple Discharge None Date of Last Mammogram Women Only Do you have a family history of breast cancer? Do you have a family history of breast cancer? Women Only Yes No If yes, what is their relationship to you and at what age were they diagnosed? Women Only Conditions Check conditions you have or have had in the past. Conditions Conditions Aids Alcoholism Anemia Anxiety Asthma Bipolar Bleeding Disorder/Clot Cancer Cirrhosis Connective Tissue Disease Depression Diabetes Drug Abuse Emphysema (COPD) Epilepsy Heart Disease Hepatitis Hernia High Blood Pressure High Cholesterol History of Wound HIV Positive Hypothyroidism/Thyroid Disease Infection Kidney Disease Pace Maker Schizophrenia Sleep Apnea STD Stroke Ulcer Unhealed Sores None Please list any other conditions you have. Recent Hospitalizations/Surgeries List your recent hospitalizations/surgeries. Please include the year, reason/surgery type, and the outcome. Recent Hospital /Surgery Recent Hospital /Surgery Recent Hospital /Surgery Recent Hospital /Surgery Recent Hospital /Surgery Allergies Please list all patient allergies (Food, medication, etc.). Allergy and Reaction Allergy and Reaction Allergy and Reaction Allergy and Reaction Allergy and Reaction Allergy and Reaction Allergy and Reaction Allergy and Reaction Medications List all current medications. Please include the name, dose, and how many times per day you take it. Medication Medication Medication Medication Medication Medication Medication Medication Family History Check if your blood relatives had any of the following: Asthma, Hay Fever Asthma, Hay Fever Yes No If yes, what is their relationship to you? Bleeding / Clotting Disorder Bleeding / Clotting Disorder Yes No If yes, what is their relationship to you? Cancer Cancer Yes No If yes, what is their relationship to you? Chemical Dependency Chemical Dependency Yes No If yes, what is their relationship to you? Diabetes Diabetes Yes No If yes, what is their relationship to you? Heart Disease, Strokes Heart Disease, Strokes Yes No If yes, what is their relationship to you? High Blood Pressure High Blood Pressure Yes No If yes, what is their relationship to you? Please list any other family history conditions. Social History Check what applies to you. Smoke cigarettes? Smoke cigarettes? Yes No Current Smoker: How many packs a day do you smoke and for how many years? Ex-Smoker: When did you quit, how many packs a day did you smoke, and for how many years? Other Tobacco: Other Tobacco: Check all that apply. Pipe Cigar Snuff Chew None Do you drink alcohol? Do you drink alcohol? Check all that apply. No Wine Beer Liquor How many drinks do you have a week? Have you ever used needles to inject drugs? Have you ever used needles to inject drugs? Yes No Do you use marijuana or other recreational drugs? Do you use marijuana or other recreational drugs? Yes No Marital Status Marital Status Single Married Divorced Separated Widowed Other Years of education or Highest Degree Signature and Acknowledgement Please read and sign below. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the physician/provider of any changes in my medical status and of my current list of medications. Signature of Patient or Responsible Party Be sure to save your signature. SaveClear Date Submit Patient Form
