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703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
PATIENT INFORMATION
BREAST CENTER
NAME
1
Patient
Information
LAST
FIRST
BIRTHDATE
AGE
ADDRESS
NO.
FEMALE
SOCIAL SECURITY
STREET
APT. NO.
CITY
REFERRING DOCTOR
MALE
MIDDLE
STATE
ZIP
PRIMARY CARE DOCTOR
TELEPHONE
HOME
WORK
CELL
EMAIL
NAME OF SPOUSE OR PARENT OR GUARDIAN
OCCUPATION
DRIVER’S LICENSE #:
EMPLOYER
EMPLOYER ADDRESS
EMERGENCY CONTACT
PRIMARY
PRIMARY INSURANCE
CARDHOLDER’S NAME
2
CARDHOLDER’S RELATIONSHIP TO PATIENT
Insurance
Information
REFERRAL REQUIRED *
POLICY NUMBER
CARDHOLDER DATE OF BIRTH
CARDHOLDER’S SOCIAL SECURITY #
COPAY AMOUNT *
REFERRAL OBTAINED
*If you are unsure about your specialist co-pay amount or if you are required to
have a referral from your primary care doctor to be seen by our office, call the
number on the back of your insurance card to verify prior to your appointment.
SECONDARY
SECONDARY INSURANCE
POLICY NUMBER
CARDHOLDER’S NAME
CARDHOLDER’S SOCIAL SECURITY #
CARDHOLDER’S RELATIONSHIP TO PATIENT
REFERRAL REQUIRED *
COPAY AMOUNT *
REFERRAL OBTAINED
PLEASE PRESENT ALL INSURANCE CARDS & REFERRALS TO THE RECEPTIONIST
3
Assignment
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled to Surgical
Specialists of Northern Virginia, LLC for services rendered by Surgical Specialists of Northern Virginia, LLC. This
assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid
as the original. I hereby assume financial responsibility for all charges whether or not paid by said insurance. I hereby
authorize said assignee to release all information necessary to secure payment.
I understand that Surgical Specialists of Northern Virginia, LLC and/or the National Breast Center reserve the right to
pursue delinquent accounts via third party collection agencies or attorneys. In the event that this account is referred to
collections, I agree to be responsible for all costs of collections including attorney’s fees in the amount of 25% of the
outstanding balance due at the time of referral to collections. I agree to pay 1 & 1/2 percent per month interest (18% per
year), on all accounts which are unpaid after (30) days. I further state that this contract is being executed in Fairfax County,
and agree that venue for any action to collect unpaid bills shall be in Fairfax County, Virginia.
Signature _________________________________________ Date ________________
BREAST CENTER
PRIVACY PRACTICES
ACKNOWLEDGEMENT
AND CONSENT FORM
703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
I understand that, under the Health Insurance Portability & Accountability Act of
1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
Conduct, plan, and direct my treatment and follow-up among the
multiple healthcare providers who may be involved in that treat
ment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as the business aspects
of running the practice on a daily basis.
I have read and understood your Notice of Privacy Practices containing a more
complete description of the uses and disclosures of my health information.
Patient Name:
Signature:
Relationship to Patient:
Name if other than patient:
Date:
CARE ACCESSS POLICY
703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
BREAST CENTER
We have created new office standards that will enable us to offer more timely appointments to you.
If you need to reschedule for any reason, please call us so we can accommodate you, and make your
spot available to another patient who needs it. Because we are a cancer screening and treatment
center, we have developed a cancellation policy to maximize access for urgent appointments and
limit wait times for those with the greatest need.
$50 Per Missed Appointment Without 24 Hour Prior Notice
$100 Per Missed Procedure Without 24 Hour Prior Notice
$250 Per Elective Surgery Cancellation Without 1 Week Notice
I understand and agree to abide by the above policy.
Patient Name (printed) __________________________________
Patient Signature: ________________________________ Date Signed ________________
Responsible Party Name (printed) __________________________________
Responsibily Party Signature: ________________________ Date Signed ________________
Special Reminder
Bringing your discs, films, reports, insurance card,
and correct referral (if your insurance requires it)
can help keep your care treatment plan on track.
In most cases, you will need to go the imaging
facility to pick up the actual films and reports;
imaging facilities usually do not send them in the
mail. Be sure you have everything with you the day
of your visit and allow at least 2 hours plus your
travel time, in case we need to run additional tests
for you. We plan to work together with you as a
team and we promise to give you our very best at
every appointment.
703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
CONTACT ME
BREAST CENTER
NAME
LAST
FIRST
1
BIRTH DATE
MALE
FEMALE
It is imperative that we be able to reach you in a timely manner in order to enable us to
provide you with the best quality care. As a consideration for our staff and patients, we
ask that you provide effective contact information to our office.
The best number to reach me: ___________________________
This is my cell
home
work number other
Please only call me at this number between this time window: _______am/pm to _______am/pm
I authorize the National Breast Center to leave messages containing the following info at the above number:
appointment reminders
medical information
billing information
Other phone numbers that messages regarding appointment reminders and call back requests can be left:
____ ___________ this is my ______________________________ number
____ ___________ this is my ______________________________ number
____ ___________ this is my ______________________________ number
I would be happy to receive appointment reminder text messages at this number ___________________
2
3
I would be happy to receive email correspondence at ___________________________________________
regarding my
appointment reminders
medical information
billing information
I designate the following person(s) as an authorized contact for the National Breast Center to speak to about
my medical situation.
Name: _______________________________________ Relationship to patient: ______________________
Best phone number to reach:__________________
Name: _______________________________________ Relationship to patient: ______________________
Best phone number to reach:__________________
Name: _______________________________________ Relationship to patient: ______________________
Best phone number to reach:__________________
Signature _________________________________________ Date ________________
AUTHORIZATION TO RELEASE
HEALTHCARE INFORMATION
703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
BREAST CENTER
At times it may be necessary for us to obtain copies of reports and medical records that are
related to your condition from other facilities. The following release is used to give us
permission to request your records.
NAME
LAST
FIRST
BIRTH DATE
SOCIAL SECURITY #
I request and authorize ___________________________________ to release healthcare
information of the patient named above to:
National Breast Center
8988 Lorton Station Blvd . 202
Lorton, VA 22079
Fax 703-763-4355
This request and authorization applies to:
Healthcare information relating to the following treatment, condition, or dates: ________
_________________________________________________________________________
All healthcare information
Other: ____________________________________________________________________
Patient Signature: ________________________________ Date Signed ________________
MEDICAL QUESTIONNAIRE
703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
BREAST CENTER
NAME
LAST
FIRST
BIRTH DATE
MALE
FEMALE
PAST SURGICAL HISTORY
List All Prior Surgeries and the Year They Were Done
1. _______________________________________________________________________Year__________
2. _______________________________________________________________________Year__________
3. _______________________________________________________________________Year__________
4. _______________________________________________________________________Year__________
5. _______________________________________________________________________Year__________
6. _______________________________________________________________________Year__________
7. _______________________________________________________________________Year__________
8. _______________________________________________________________________Year__________
9. _______________________________________________________________________Year__________
10. ______________________________________________________________________Year__________
MEDICAL HISTORY
Please mark any condition you have been diagnosed with:
Arthritis
Asthma
Emphysema
COPD
Kidney Disease
Thyroid Disease ______________________________________________________________________
Diabetes
Type I
Type II
High Blood Pressure
Stroke
Heart Problems
Palpitations
Chest Pain
Other_____________________________________
HIV / AIDS
High Cholesterol
Cancer _____________________________________________________________________________
REVIEW OF SYMPTOMS (Please mark all that apply)
GENERAL
Weight Loss / Gain
Fever / Chills
Bleed / Bruise Easily
Blood Transfusion
Anemia
URINARY TRACT PROBLEMS
Frequent Urination
Blood in Urine
Prostate Trouble
STOMACH PROBLEMS
Constipation
Diarrhea
Nausea / Vomiting
Ulcers
Heartburn
Liver Disease
LUNG PROBLEMS
Cough
Shortness of Breath
NEUROLOGICAL PROBLEMS
Seizures
Head Injury Date: _______________ Type: ___________________________________________
Headaches
Numbness / Weakness Location: __________________________________________________
MEDICAL QUESTIONNAIRE
703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
BREAST CENTER
NAME
LAST
FIRST
CURRENT MEDICATIONS
1. ________________________________________
2. ________________________________________
3. ________________________________________
4. ________________________________________
5. ________________________________________
6. ________________________________________
7. ________________________________________
8. ________________________________________
9. ________________________________________
10. _______________________________________
11. _______________________________________
12. _______________________________________
13. _______________________________________
14. _______________________________________
15. _______________________________________
ALLERGY
Reaction (Circle One)
1. ____________________ Mild
Moderate
2. ____________________ Mild
Moderate
3. ____________________ Mild
Moderate
4. ____________________ Mild
Moderate
5. ____________________ Mild
Moderate
6. ____________________ Mild
Moderate
7. ____________________ Mild
Moderate
8. ____________________ Mild
Moderate
9. ____________________ Mild
Moderate
10. ___________________ Mild
Moderate
BIRTH DATE __________________
Dosage
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Symptoms
Severe _____________________________________
Severe _____________________________________
Severe _____________________________________
Severe _____________________________________
Severe _____________________________________
Severe _____________________________________
Severe _____________________________________
Severe _____________________________________
Severe _____________________________________
Severe _____________________________________
SOCIAL HISTORY
Occupation _________________________________________________________________________
Do You Smoke?
Yes
No Amount ___________________________________________
Do You Drink Alcohol? Yes
No Amount ___________________________________________
Do You Use Recreational Drugs?
Yes
No Amount _________________________________
FAMILY HISTORY
(Please Indicate Relationship: )
Cancer
High Blood Pressure
Diabetes
Stroke
Heart Disease
Thyroid Disease
Mother
Mother
Mother
Mother
Mother
Mother
Father
Father
Father
Father
Father
Father
Sibling
Sibling
Sibling
Sibling
Sibling
Sibling
Maternal Grandparent
Maternal Grandparent
Maternal Grandparent
Maternal Grandparent
Maternal Grandparent
Maternal Grandparent
Paternal Grandparent
Paternal Grandparent
Paternal Grandparent
Paternal Grandparent
Paternal Grandparent
Paternal Grandparent
BREAST QUESTIONNAIRE
703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
BREAST CENTER
NAME
AGE
LAST
FIRST
DATE
BIRTHDATE
Referring Physician(s): ________________________________________________________________________________
Date of Last Mammogram: ______________________ Location (What facility?) ________________________________
Date of Last breast ultrasound:___________________ Location (What facility?) ________________________________
Current problem(s) / concern(s):
Which breast:
(mark all that apply)
Left
Right
Both
Abnormal imaging
Pain
Nipple discharge 2nd opinion
Lump
When noticed?_________________________ By whom?___________________________________
Has it changed?
No Yes How?___________________________________________________
Does if vary with your natural menstrual cycle?
No Yes How? _________________________
Have you had a biopsy for this?
No Yes Results? ____________________________________
Skin Changes ______________________________________________________________________________
Other ____________________________________________________________________________________
Do you perform self breast exams?
No Yes How often? ____________________________________________
Do you regularly consume caffiene (coffee, tea, soda, chocolate)?
Daily Weekly
Other __________________
Have you had other breast problems?
No Yes
Type of problem? _________________________ Which breast:
Left
Right
Both
When? _________________________ Results: __________________________________________________
Have you had breast cancer in the past?
No Yes When?______________________________________________
Was it invasive?
No
Yes Don’t know
Treatment:________________________________________________________________________________
Chemotherapy?
No
Yes
Radiation?
No
Yes
Have you ever taken: Tamoxifen
Arimidex
Femara
Other anti estrogens _________________________
When? _____________How Long? ____________________________________________________________
Reason?__________________________________________________________________________________
Are you currently breastfeeding ?
Do you still have periods?
No
Yes
Have you breastfed in the last 6 months?
No
Yes
Yes - Start date last menses_________________
No - Age at menopause?______
Natural Surgical Chemo Birth Control Induced
Ovaries Removed: one both
Hysterectomy - reason for ___________________________________________________
Have you ever taken birth control pills: No Yes
How long?: Start (month / year): _________________ Stopped (month/year):__________________
Have you ever taken fertility drugs?
No
Yes When? ______________ How Long?__________________________
Have you ever taken hormone replacement therapy (estrogen/progesterone)? No Yes
What type of hormone replacement therapy?____________________________________________
How long?: Start (month / year): _________________ Stopped (month/year):__________________
Have you ever had genetic testing for breast or ovarian cancer? No Yes
Results___________________________________________
FAMILY HISTORY
SCREENING
QUESTIONNAIRE
BREAST CENTER
NAME
AGE
703-763-4355 fax 703-763-4365
www.nationalbreastcenter.com
LAST
DATE
FIRST
BIRTHDATE
Are you adopted?
Yes
No
Please list any family history (mother, father, grandparent, sister, brother, aunt, uncle, cousin, niece, nephew) who has
or has had any of the listed forms of cancer:
No known family history
Relationship
to You
Mother’s side
or
Father’s side
Ex. Aunt_________
________________
________________
________________
________________
________________
M
M
M
M
M
M
F
F
F
F
F
F
Type of Cancer (including
breast, ovarian, colon,
pancreatic)
breast
breast
breast
breast
breast
breast
ovarian
ovarian
ovarian
ovarian
ovarian
ovarian
colon
colon
colon
colon
colon
colon
Approximate
Age of
Diagnosis
pancreatic
pancreatic
pancreatic
pancreatic
pancreatic
pancreatic
__65___
_______
_______
_______
_______
_______
What is your nationality (country of origin)?
Mother’s side: _________________________________
Father’s side: _________________________________
Ancestry and Clinical History:
Western/ Northern Europe
Latin American/ Caribbean
Near East/ Middle East
Ashkenazi
Africa
Native American
Central/ Eastern Europe
Asia
Other ____________________
Don’t know