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Tell Us About You


                  Patient:

 

First Name  
Last Name
Middle Initial
Street Address  
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone  

Patient's Social Security Number 

Patient's Date Of Birth 

 

Medical Information

 

Patient's Doctor  

Phone number with area code  

 

Mailing Address
Mailing Address (cont.)
City.  
State/Province.
Zip/Postal Code.

 

Insurance Information

 

Primary Insurance Company 

Insurance Company 

Policy Holder's Date Of Birth  
Policy number
Group number
Name on card
Activation Date
Phone Number 
Insurance Mailing Address
Mailing-Address (cont.)
City.
State/Province.
Zip/Postal Code.

 

Secondary Insurance Company (if applicable)

Insurance Company 

Policy Holder's Date of birth
Policy number
Group number
Name on card
Activation Date
Phone Number 
Insurance Mailing Address
Mailing-Address (cont.)
City.
State/Province.
Zip/Postal Code.

 

Product Information

Please tell us what products you use 

What type of Catheter do you use: Please note the reorder number is on the box they come in or an REF number can be found on the wrapping of a new one. In order to serve you better please be specific:


 

Frequency of Catheterization (indicate maximum)   

 

What type of under pads do you use?

Small
Medium
Large
Thick
Thin

Do you use Lubricant such as KY-Jelly or Surgi-lube?

Yes No
Do you prefer 4 ounce tube or gram packs?  

 

Type of gloves you use::

Powder-free
Latex-free
What size glove do you use?   Small/Medium/Large  
Does the patient have latex allergies Yes/NO?  

 

Type of diapers: If you don't use diapers just put none:


Do you use antiseptic wipes?

Yes No

 

 Do you use any miscellaneous items?

 Please list items with brand names, size, and reorder numbers if possible!



Heartline Medical of The Lower Cape Fear
Copyright � 2001 . All rights reserved.
Revised: Feb 14th 2008