HERNIA INSTITUTE OF PENNSYLVANIA
North Penn Hernia Institute
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PATIENT'S NAME (Last)___________________(First)_________________(MI)____
HOME ADDRESS -STREET_______________________________
CITY__________________________STATE_______ZIP_________
E-MAIL Address_________________@________________
DATE OF BIRTH mm/dd/yy ____/____/_____ Social Security Number______-____-_____
HOME PHONE NUMBER AC(______)______-___________
CELL PHONE* (_____)_____-_________ or *Local # in NP Area (i.e. Hotel) to contact you
EMERGENCY CONTACT PERSON____________________________
EMERG.CONTACT'S DAY PHONE # _____-_____-_________

HOTEL NAME (*REQUIRED if staying in the North Penn area from out of town.)__________________________________* If not yet known, please notify us when arrangements made.
MARITAL STATUS______________SPOUSE'S NAME______________________
DO YOU SMOKE?(circle) YES - NO - IF YES, HOW MUCH_____________
DO YOU DRINK ALCOHOL(circle) YES - NO - HOW MUCH_____________
HEIGHT_______FT_______INCHES: - WEIGHT____________POUNDS

EMPLOYER___________________________OCCUPATION_________________
WORK ADDRESS__________________________CITY___________STATE______ZIP__________
WORK PHONE NUMBER (________)_______-___________ EXTENSION__________

TYPE OF HERNIA________________(Inguinal, Umbilical, Femoral, Incisional etc.)
LEFT or RIGHT (CIRCLE SIDE if appropriate) How Long Present?___________________
SYMPTOMS(circle All that apply):Pain-Bulge-Nausea-Urinary Symptoms-Bowel Symptoms
OTHER SYMPTOMS(describe briefly)_________________________________________________

LIST ALL PRIOR OPERATIONS (include year if known)_____________________
______________________________________________________________________
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LIST ALL CURRENT MEDICATIONS AND DOSES (include any Vitamins, Supplements, Aspirin etc.)
______________________________________________________________________
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CHECK ANY and ALL THAT APPLY -PAST or PRESENT HISTORY MUST BE INCLUDED
HEART DISEASE**________(IF YES, WHAT?)_______________ DIABETES ________
HIGH BLOOD PRESSURE_______LUNG DISEASE _______SEIZURES _______
OTHER MAJOR MEDICAL PROBLEMS__________________LATEX ALLERGY_______
NOTE**Patients with ANY significant past cardiac (heart) history must provide us with a comprehensive medical evaluation from their Cardiologist or Internist prior to surgery.



LIST OTHER PERTINENT MEDICAL HISTORY(PAST or PRESENT)
____________________________________________________________________
____________________________________________________________________
DRUG or OTHER ALLERGIES?____________________________________________

FAMILY MEDICAL HISTORY (Alive-Deceased?/ Chronic Illnesses? etc.)
MOTHER_________________FATHER_________________
BROTHERS_________________SISTERS______________

**FAMILY PHYSICIAN-We will provide Records/Reports of your care to your Physician
NAME_________________________________MD/DO
STREET ADDRESS_______________________________SUITE#_______________
CITY__________________________STATE_______ZIP________________
PHONE#(_____)_______-__________ Fax#(_____)_______-__________
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PHARMACY __________________________ PHONE#(_____)_______-__________< br> CITY__________________________STATE_______ZIP________________
INSURANCE INFORMATION
It will be your full responsibility to remit any Co Pay or Deductible amount that is part of your insurance plan contract
PRIMARY INSURANCE CARRIER______________________________
ADDRESS_______________________________________________
CITY____________________________STATE____________ZIP___________
ID NUMBER________________________GROUP NUMBER_________________________
SUBSCRIBER'S NAME_____________________________
SUBSCRIBER'S DATE OF BIRTH mm/dd/yy____/_____/_____
PHONE # FOR AUTHORIZATION(on membership card)____-____-_____ext._______

SECONDARY INSURANCE CARRIER______________________________
ADDRESS_______________________________________________
CITY____________________________STATE____________ZIP___________
ID NUMBER________________________GROUP NUMBER_________________________
SUBSCRIBER'S NAME_____________________________
SUBSCRIBER'S DATE OF BIRTH mm/dd/yy____/_____/_____
PHONE # FOR AUTHORIZATION(on membership card)____-____-_____ext._______

I AUTHORIZE THE RELEASE OF ALL MEDICAL INFORMATION ONLY AS NECESSARY TO PROCESS MY INSURANCE CLAIM. I ASSIGN ALL MEDICAL AND SURGICAL INSURANCE BENEFITS TO NORTH PENN HERNIA INSTITUTE (NORTH PENN SURGICAL ASSOCIATES). THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES. I HAVE READ AND FULLY UNDERSTAND THIS INFORMATION. THE INFORMATION PROVIDED ON THE TWO (2) PAGES ABOVE IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
________________________________________ Date____/______/_____
SIGNATURE IS REQUIRED TO PROCESS INSURANCE CLAIM (Patient or Legal Guardian if minor)
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