• PRECISION

    Regenerative & Functional Medicine

  • Thank you for choosing Precision Regenerative and Functional Medicine. Please completely fill out this form to ensure the fastest and best service. We may ask you to look over this information from time to time to make sure it stays up-to-date.

    If you are able to complete this paperwork in advance please arrive 15 minutes prior to your scheduled time. If you would like to complete the paperwork at our office please arrive 45 minutes prior to your scheduled time.

    *Your appointment will be rescheduled if you are not able to complete this form prior to your scheduled time.

    Please note:

    *If the patient is a minor, they will need to be accompanied by their legal guardian.

    *Be sure to list all drug allergies.

    *We will need all guarantor/ responsible party information.

    *A complete list of all medications is needed.

    *Bring your insurance card(s) and your co-payment.

    *Bring any medical records, x-rays, MRIs, CT scans, etc.

    *All canceled appointments must be called in at least 24 hours prior to your scheduled appointment

    **IN THE EVENT YOU FORGET YOUR X-RAYS OR MRI SCANS, THE OFFICE WILL RESCHEDULE YOUR APPOINTMENT**

    If you have any questions, please call us at (512) 892-0490.

  • Date of birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Marital Status
  • Preferred Language
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Health Insurance

  • Do you have secondary insurance?
  • Are you covered under the policy of a spouse, partner, parent, or legal guardian?
  • Sex
  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Financial Policy and Assignment of Benefits

    Precision Regenerative and Functional Medicine is dedicated to providing the best possible care and service to you. We regard your understanding of all your financial responsibilities as an essential element of your treatment.

    * We have made prior arrangements with many insurers and health plans (HMO & PPO) to accept an assignment of benefits. We will bill those plans and will only require you to pay the authorized copayment, coinsurance and/or deductible at the time of service. The office policy is to collect this copayment, coinsurance and/or deductible when you arrive for your appointment. This amount is an estimate and is based on the most recent insurance verification obtained by our office staff.

    * If your insurance policy requires a referral for Precision Regenerative and Functional Medicine, please understand we will request this referral from your referring practitioner prior to your appointment, but it is ultimately your responsibility to obtain this referral. If your services are denied because the referral was not received, you will be responsible for the full charged amount.

    * Private pay patients are required to pay in full at the time of service. A quote will be provided for any and all procedures prior to your appointment.

    * We accept VISA, Mastercard, and Discover. Please be advised that there is a $20 service charge on all returned checks.

    * Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you, if you assign the benefits to our doctor. If your insurance company does not pay our office within 90 days, you will be responsible for payment. If we later receive a check from your insurer, we will refund any overpayment.

    * All health plans are not the same and do not cover the same services. In the event that your health plan determines a service to be "not covered" you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.

    * If you have a medical procedure performed by our physician at a location other than our office you and/or your insurance company will receive two bills, one from our physician for his professional services and one from the facility where the procedure was performed.

    * For all services rendered to minor patients, the parent and/or legal guardian will be responsible for payment.

    * If you receive a statement from Precision Regenerative and Functional Medicine the balance needs to be paid in full within 30 days of receipt unless prior arrangements have been made. Any remaining balances due after 90 days will be considered delinquent and will be turned over to an outside collection agency. Future appointments will not be scheduled until balances have been paid in full or a written payment plan has been agreed to by our office. Please be sure to update any contact changes with our office staff so you can be reached regarding your balance.

    * In order to provide the best possible service and availability to all our patients, please call us as early as possible if you know you will need to reschedule your appointment. Please see the attached cancelation no show polices and fees.

    *I hereby assign all medical and surgical benefits, to include major medical benefits, to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and other health/medical plan, to issue payment check(s) directly to Precision Pain Consultants for medical services rendered to myself and/ or my dependents regardless of my insurance. In the event that the insurance payment is sent directly to me, I realize that I will be billed personally until the balance is paid.

    I have read and understand the financial policy and assignment of benefits of the practice and I agree to be bound by its terms. I also understand and agree that the practice may amend such terms from time-to-time.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • CANCELATION AND NO SHOW POLICIES AND FEES

    This is a reminder of our policy regarding missed appointments. When one patient misses their appointment and does not let us know, or when one patient cancels their appointment late (less than 24 hours prior to the appointment), it not only affects our staff, but also other patients.

    As you know, our patients are in pain. They like to be seen and treated as soon as possible. We do our best to see and treat everybody as soon as we can, but also allow enough time on our schedule for every patient to be heard and examined, and for questions to be answered. We are respectful of our patients' time, and we ask our patients to be respectful of our time.

    When somebody does not call to cancel their appointment and simply just does not show up, or calls and cancels their appointment at the last minute, we cannot schedule another patient on such short notice. We lose time that day and somebody else continues to wait to see us, while suffering in pain.

    Charging for missed appointments is not something we like to do. It can be avoided with a minimum of courtesy and good communication. Please help us continue to treat you and everybody else at the standards you deserve.

    FOLLOW-UP APPOINTMENTS

    NO-SHOW OR MISSED WITHOUT 24 HOURS NOTICE WILL BE CHARGED $50.00

    CANCELED WITH LESS THEN 24 HOURS NOTICE WILL BE CHARGED $25.00

    IF YOU ARRIVE MORE THAN 15 MINUTES LATE FOR A FOLLOW UP APPT, YOUR APPT MAY BE RESCHEDULED AND YOU WILL BE CHARGED $25.00 (at discretion of the provider) 

    PROCEDURE APPOINTMENTS

    NO-SHOW OR MISSED WITHOUT 24 HOURS NOTICE WILL BE CHARGED $150.00

    CANCELED WITH LESS THAN 24 HOURS NOTICE WILL BE CHARGED $50.00

    NEW PATIENT APPOINTMENTS

    NO-SHOW OR MISSED WITHOUT 24 HOURS NOTICE WILL BE CHARGED $50.00

    CANCELED WITH LESS THAN 24 HOURS NOTICE WILL BE CHARGED $25.00

     

    FEES NEED TO BE PAID IN FULL BEFORE APPTS WILL BE RESCHEDULED

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • AUTOMATIC BILLING AUTHORIZATION FORM

  • FROM CREDIT CARD:

    I authorize you to charge my bill directly to the credit card(s) listed below:

  • Today's Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • AUTOMATIC BILLING AUTHORIZATION FORM

  • Do you want to add a second credit card?
  • Expiration Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Today's Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • AUTOMATIC BILLING AUTHORIZATION FORM

    • Bill all charges to the above card(s). Since the payment amount may vary, I will receive written notification of the amount and date of the next charge prior to each scheduled transaction date.
    • This authorization is valid until I provide you with written cancellation.
    • I authorize the charge of all copays, co-insurance or deductible amounts due for all in office and telemedicine visits.
    • I authorize the charge of all No-Show or Missed appointment fees. I have reviewed and signed the Cancelation and No-Show Polices and Fee document.
    • I authorize the charge for all clinic lab fees for labs drawn at PRFM.
    • I authorize the charge for any peptides, HRT products that are ordered and paid for by PRFM and shipped directly to my home.
    • I authorize the charge for any unpaid balances over 30 days old.
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Authorization for Release and Disclosure of Protected Health Information

  • In accordance with state law and regulatory agency requirement, the health record is the property of Precision Pain Consultants (PPC). I hereby authorize the PPC/PRFM Medical Records custodian to release information from the medical records of:

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Authorization for Release and Disclosure of Protected Health Information

  • INFORMATION MAY BE RELEASED TO:

    PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE

    1101 S. CAPITAL OF TEXAS HWY

    BUILDING F, STE. 101

    AUSTIN, TEXAS 78746

    (512) 892-0490

  • Facility or Physician

    Provide contact information below
  • Format: (000) 000-0000.
  • Please release the following information:
  • This information is necessary for the following:

  • Authorization for Release and Disclosure of Protected Health Information

  • 1. I understand that the information in my health record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol/drug abuse.

  • 2. I UNDERSTAND THAT I HAVE A RIGHT TO REVOKE THIS AUTHORIZATION AT ANY TIME. I UNDERSTAND THAT IF I REVOKE THIS AUTHORIZATION I MUST DO SO IN WRITING AND PRESENT MY WRITTEN REVOCATION TO THE HEALTH INFORMATION THAT HAS ALREADY BEEN RELEASE IN RESPONSE TO THIS AUTHORIZATION. I UNDERSTAND THAT THE REVOCATION WILL NOT APPLY TO MY INSURANCE COMPANY WHEN THE LAW PROVIDES MY INSURER WITH THE RIGHT TO CONTEST A CLAIM UNDER MY POLICY. UNLESS OTHERWISE REVOKED, THIS AUTHORIZATION WILL EXPIRE ON THE FOLLOW DAYS, EVENT, OR CONDITION: IF I FAIL TO SPECIFY AN EXPIRATION DATE, EVENT CONDITION, THIS AUTHORIZATION WILL EXPIRE IN six (6) MONTHS.
     - -
    2 digit month, 2 digit day, 4 digit year

  • 3. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this in order to assure treatment. I understand that with certain exceptions, I may inspect or copy the information to be used or disclosed. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have any questions about disclosure of my health information, I can contact the Health Information Management Manager at (512) 892-0490.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • ACKNOWLEDGMENT OF RECEIPT AND PRIVACY NOTICE

  • I,*understand that as part of my health care, Precision Regenerative and Functional Medicine originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, as well as plans for future care. 

  • I understand that this information serves as:

    * A basis for planning my treatment;

    * A means to facilitate communication amount the many healthcare professionals who contribute to my care;

    *A source of information for applying my diagnosis and surgical information to my bill;

    *A means by which a third-party payer can verify that services billed were actually provided.

    * A tool for healthcare operations of Precision Pain Consultants such as assessing quality of care and reviewing the competence of healthcare professionals. 

    I understand that as part of Precision Regenerative and Functional Medicine treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity for the purposes stated above.

    I understand I have the right to review a Notice of Privacy Practices that provides a more complete description of how Precision Regenerative and Functional Medicine may use and disclose my protected healthcare information. I further understand that Precision Regenerative and Functional Medicine reserves the right to change its Notice of Privacy Practices. Should Precision Regenerative and Functional Medicine change its Notice of Privacy Practices, an amended copy will be posted in a prominent location in the practice site, or, upon my request, an amended copy will be sent to the address I have provided.

    I agree that Precision Regenerative and Functional Medicine may do the following unless I specifically give direction prohibiting such activity:

    * Send visit reminders and test results to the address I have provided.

    * Send routine correspondence, such as billing statements, to the address I have provided.

    * Leave messages on answering machine or voicemail associated with the telephone numbers I have provided to either confirm appointments or to request that I call the practice for medical or billing matters.

    * Speak to or leave message with the familly members/friends listed below:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • PATIENT PROFILE

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • CHIEF COMPLAINT

  • Is your pain the result of a ...
  • Red Flags (Risk Factors) - answer "yes" or "no" to the following:
    Rows

  • PAST MEDICAL HISTORY

  • Have you ever had a reaction to ...
  • Current illnesses: in the last month, have you ...
    Rows
  • Do you have any of the following medical conditions:
    Rows

  • REVIEW OF SYSTEMS

  • Recently, have you had?
    Rows
  • Do you smoke?
  • Do you drink alcohol?
  • Do you have a family history of musculoskeletal or joint disease?
  • Do you have a family history of spinal disease or spinal surgery?
  • Do you have a family history of any chronic disease or condition?
  • Medication Chart: We will have you update this list every time you visit.
    Rows
  • Please check all that apply
  • Format: (000) 000-0000.

  • Medication Agreement and Instruction

  •  

    You are expected to use your medication appropriately. Do not share, sell or otherwise permit others access to your medication. Take your medication only as directed on the bottle or explained to you by the physicians or physician's assistants. Store your medication in a safe place. Count your medication at the pharmacy when receiving it.

    Only one provider (physician/physician assistant) should prescribe and maintain your medication.

    If you find your medication is not effective, do not increase your medication dosages yourself. Please email info@austinppc.com or call 512.892.0490 to speak with a medical assistant. While we try to answer everybody promptly, you must allow at most 48 hours for response to your email or call. We may schedule a follow-up appointment to discuss some issues.

    Please do not contact our office for refills. Please request your prescription refills at least 48 hours prior to medications running out, not counting Saturdays, Sundays, or holidays. This allows for proper review of your history or time for prior authorization required by insurance companies.

    In case of lost, stolen, self-increased medication or any other unexplained discrepancies, early refills will not be provided. Non-opioid medication or withdrawal medication may be offered.

    Maintain a primary care physician that you see for general or other medical care, lab testing for other acute or chronic health conditions that may require annual or routine monitoring and care.

    Provide a list of other medical conditions, medications, and other physicians and notify our office of any changes that may occur.

    Allow periodic medication monitoring by urine drug screens (UDS) and other lab testing if necessary as part of your treatment plan. In case of inconsistencies on your UDS, you will be dismissed from our care and offered one month's worth of medication and instructions on how to taper it. Do not use alcohol or take any other mind altering substances while using pain medications. Chronic opioid analgesic therapy may cause dependence, addiction or re-addiction, and tolerance.

     

  • I have read and had the opportunity to discuss the information in this MEDICATION AGREEMENT between myself, my physician or physician assistant.

  • I understand that for my safety, failure to follow the instructions detailed in this agreement may result in non-narcotic pain management treatments only, and possible dismissal from services through Precision Pain Consultants.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Modified Somatic Perception Questionnaire

    Please describe how you have felt during the past week. Please answer all questions. Do NOT think before answering.
  • Heart rate increase
  • Feeling hot all over
  • Sweating all over

  • Modified Somatic Perception Questionnaire - cont.

    Please describe how you have felt during the past week. Please answer all questions. Do NOT think before answering.
  • Sweating in a particular part of the body
  • Pulse in the neck
  • Pounding in the head
  • Dizziness

  • Modified Somatic Perception Questionnaire - cont.

    Please describe how you have felt during the past week. Please answer all questions. Do NOT think before answering.
  • Blurring of vision
  • Feeling faint
  • Everything appearing normal
  • Nausea

  • Modified Somatic Perception Questionnaire - cont.

    Please describe how you have felt during the past week. Please answer all questions. Do NOT think before answering.
  • Butterflies
  • Pain or ache in stomach
  • Stomach churning
  • Desire to pass water

  • Modified Somatic Perception Questionnaire - cont.

    Please describe how you have felt during the past week. Please answer all questions. Do NOT think before answering.
  • Mouth becoming dry
  • Difficulty swallowing
  • Muscle in neck aching
  • Legs feeling weak

  • Modified Somatic Perception Questionnaire - cont.

    Please describe how you have felt during the past week. Please answer all questions. Do NOT think before answering.
  • Muscles twitching or jumping
  • Tense feeling across forehead
  • Tense feeling in jaw muscles
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Modified ZUNG Depression Index

    Please indicate for each of these questions which answers best describe how you have been feeling recently.
  • I feel downhearted and sad.
  • Morning is when I feel best.
  • I have crying spells or feel like it.
  • I have trouble getting to sleep at night.

  • Modified ZUNG Depression Index - cont.

    Please indicate for each of these questions which answers best describe how you have been feeling recently.
  • I feel that nobody cares.
  • I eat as much as I used to.
  • I still enjoy sex.
  • I noticed I am losing weight.

  • Modified ZUNG Depression Index - cont.

    Please indicate for each of these questions which answers best describe how you have been feeling recently.
  • I have trouble with constipation.
  • My heart beats faster than usual.
  • I get tired for no reason.
  • My mind is as clear as it used to be.

  • Modified ZUNG Depression Index - cont.

    Please indicate for each of these questions which answers best describe how you have been feeling recently.
  • I tend to wake up too early.
  • I find it easy to do the things I used to.
  • I am restless and can't keep still.
  • I feel hopeful about the future.

  • Modified ZUNG Depression Index - cont.

    Please indicate for each of these questions which answers best describe how you have been feeling recently.
  • I am more irritable than usual.
  • I find it easy to make a decision.
  • I feel quite guilty.
  • I feel I am useful and needed.

  • Modified ZUNG Depression Index - cont.

    Please indicate for each of these questions which answers best describe how you have been feeling recently.
  • My life is pretty full.
  • I feel that others would be better off if I were dead.
  • I am still able to enjoy the things I used to.
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Neck Pain and Disability Scale

    Please answer each question on a scale of 1 to 10.
  • How bad is your pain today?
  • How bad is your pain on average?
  • How bad is your pain at its worst?

  • Neck Pain and Disability Scale - cont.

    Please answer each question on a scale of 1 to 10.
  • Does your pain interfere with your sleep?
  • How bad is your pain with standing?
  • How bad is your pain with walking?

  • Neck Pain and Disability Scale - cont.

    Please answer each question on a scale of 1 to 10.
  • Does pain interfere with driving or riding in a car?
  • Does your pain interfere with social activities?
  • Does your pain interfere with recreational activities?

  • Neck Pain and Disability Scale - cont.

    Please answer each question on a scale of 1 to 10.
  • Does your pain interfere with work activities?
  • Does your pain interfere with your personal care (eating, dressing, bathing, etc.)?
  • How has your pain changed your outlook on life and the future (depression, hopelessness, etc)?

  • Neck Pain and Disability Scale - cont.

    Please answer each question on a scale of 1 to 10.
  • Does pain affect your emotions?
  • Does your pain affect your ability to think or concentrate?
  • How stiff is your neck?

  • Neck Pain and Disability Scale - cont.

    Please answer each question on a scale of 1 to 10.
  • How much trouble do you have turning your neck?
  • How much trouble do you have looking up or down?

  • Neck Pain and Disability Scale - cont.

    Please answer each question on a scale of 1 to 10.
  • How much trouble do you have working overhead?
  • How much do pain pills help?

  • The Drug Abuse Screening Test (DAST)

  •  

    Directions: the following questions concern information about your involvement with drugs. Drug abuse refers to (1) the use of prescribed or "over-the-counter" drugs in excess of the directions, and (2) any non-medical use of drugs. Consider the past year (12 months) and carefully read each statement. Then decide whether your answer is YES or NO and check the appropriate space. Please be sure to answer every question.

     

  • Have you used drugs other than those required for medical reasons?
  • Have you abused prescription drugs?
  • Do you abuse more than one drug at a time?
  • Can you get through the week without using drugs? (other than those required for medical reasons)

  • The Drug Abuse Screening Test (DAST) - cont.

  • Are you always able to stop using drugs when you want to?
  • Do you abuse drugs on a continuous basis?
  • Do you try to limit your drug use to certain situations?
  • Have you had "blackouts" or "flashbacks" as a result of drug use?

  • The Drug Abuse Screening Test (DAST) - cont.

  • Do you ever feel bad about your drug abuse?
  • Does your spouse (or parents) ever complain about your involvement with drugs?
  • Do your friends or relatives know or suspect you abuse drugs?
  • Has drug abuse ever created problems between you and your spouse?

  • The Drug Abuse Screening Test (DAST) - cont.

  • Has any family member ever sought help for problems related to your drug use?
  • Have you ever lost friends because of your use of drugs?
  • Have you ever neglected your family or missed work because of your use of drugs?
  • Have you ever been in trouble at work because of drug abuse?

  • The Drug Abuse Screening Test (DAST) - cont.

  • Have you ever lost a job because of drug abuse?
  • Have you gotten into fights when under the influence of drugs?
  • Have you ever been arrested because of unusual behavior while under the influence of drugs?
  • Have you ever been arrested for driving while under the influence of drugs?

  • The Drug Abuse Screening Test (DAST) - cont.

  • Have you engaged in illegal activities in order to obtain drugs?
  • Have you ever been arrested for possession of illegal drugs?
  • Have you ever experienced withdrawal symptoms as a result of heavy drug intake?
  • Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?

  • The Drug Abuse Screening Test (DAST) - cont.

  • Have you ever gone to anyone for help for a drug problem?
  • Have you ever been in a hospital for medical problems related to your drug use?
  • Have you been treated as an outpatient for problems related to drug abuse?
  • Have you been treated as an outpatient for problems related to drug abuse?
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • SOAPP-R

  • The following are some questions given to patients who are on, or being considered for medication, for their pain. Please answer each question as honestly as possible. There are no right or wrong answers.

  • How often do you have mood swings?
  • How often have you felt a need for higher dose of medication to treat your pain?
  • How often have you felt impatient with your doctors?
  • How often have you felt that things are just too overwhelming that you can't handle them?

  • SOAPP-R - cont.

  • How often is there tension in the home?
  • How often have you counted pain pills to see how many are remaining?
  • How often have you been concerned that people will judge you for taking pain medication?
  • How often do you feel bored?

  • SOAPP-R - cont.

  • How often have you taken more pain medication than you were supposed to?
  • How often have you worried about being left alone?
  • How often have you felt a craving for medication?
  • How often have others expressed concern over your use of medication?

  • SOAPP-R - cont.

  • How often have any of your close friends had a problem with alcohol or drugs?
  • How often have others told you that you had a bad temper?
  • How often have you felt consumed by the need to get pain medication?
  • How often do you run out of pain medication early?

  • SOAPP-R - cont.

  • How often have others kept you from getting what you deserve?
  • How often, in your lifetime, have you had legal problems or been arrested?
  • How often have you attended an AA or NA meeting?
  • How often have you been in an argument that was so out of control that someone got hurt?

  • SOAPP-R - cont.

  • How often have you been sexually abused?
  • How often have others suggested that you have a drug or alcohol problem?
  • How often have you had to borrow pain medications from your family or friends?
  • How often have you been treated for an alcohol or drug problem?
  • Should be Empty: