Dallas Bariatric Center

NEW PATIENT INFORMATION
NIRMAL S. JAYASEELAN, M.D .. P.A.
GENERAL AND LAPAROSCOPIC SURGERY
11970 NORTH CENTRAL EXPRESSWAY SUITE 670
DALLAS, TX 75243
972.331.1111 (OFFICE)
972.331.1112 (FAX)

General Information
FULL NAME:

First Name Last Name
Date of birth:

Month Day Year
Age:
HEIGHT:
WEIGHT:
SEX:

M F
STREET ADDRESS:

Street Address

APT/UNIT

City State / Province

Postal / Zip Code
SSN:
E-MAIL ADDRESS:
CELL PHONE: *
WORK PHONE:
EXT:
EMPLOYER:
OCCUPATION
EMPLOYER ADDRESS:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
MARITAL STATUS:

MARRIED SINGLE DIVORCED WIDOWED
NUMBER OF CHILDREN:

Insurance Information
INSURANCE PROVIDER (If no insurance, say "None" and skip to the next section.) *
PROVIDER PHONE NUMBER
GROUP NUMBER
SUBSCRIBER/MEMBER ID

Primary Insured Information (If Different From Patient)
NAME:
BIRTH DATE:

Month Day Year
Date
RELATIONSHIP TO PATIENT:
STREET ADDRESS:

Street Address

APT/UNIT

City State / Province

Postal / Zip Code
SSN

EMERGENCY CONTACT
NAME
RELATIONSHIP
CONTACT PHONE
RESPONSIBILITY PARTY STATEMENT: AS THE RESPONSIBLE PARTY, I AGREE THAT ALL CHARGES THAT ARE NOT DIRECTLY PAID BY MY INSURANCE WILL BE MY RESPONSIBILITY.
SIGNATURE *
DATE

Month Day Year
Date
PRIMARY CARE PHYSICIAN’S NAME/LOCATION/TELEPHONE:
PHARMACY NAME/LOCATION/TELEPHONE NUMBER:
HOW DID YOU HEAR ABOUT US?

MEDICAL HISTORY QUESTIONNAIRE
HEIGHT
WEIGHT
ALLERGIES TO MEDICATIONS

MEDICATIONS: PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

	NAME	DOSAGE
1
2
3
4
5

PAST SURGICAL HISTORY: PLEASE LIST SURGICAL OPERATIONS

FAMILY HISTORY: PLEASE INDICATE FAMILY MEMBERS HAVING ANY OF THE FOLLOWING ILLNESSES (RELATIONSHIP)

	ALIVE/DECEASED	CURRENT AGE	AGE AT DEATH	MEDICAL ILLNESS CAUSE OF DEATH
MOTHER
FATHER
SIBLINGS
CHILDREN

HOW MANY YEARS HAVE YOU BEEN OVERWEIGHT?
HEAVIEST WEIGHT:
PREVIOUS WEIGHT LOSS SURGERY?

YES NO

OBESITY RELATED MEDICAL HISTORY

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING ILLNESSES OR SYMPTOMS?

	YES	NO	YEAR OF DIAGNOSIS
HEART DISEASE:
ANGINA:
MI (HEART ATTACK)
CORONARY BYPASS SURGERY
ABNORMAL HEART BEAT
CONGESTIVE HEART FAILURE
HIGH BLOOD PRESSURE
ELEVATED CHOLESTEROL
ELEVATED TRIGLYCERIDES
ASTHMA
REFLUX
HEART BURN
ESOPHAGITIS
HIATAL HERNIA
SHORTNESS OF BREATH

HOW MANY BLOCKS CAN YOU WALK?
FLIGHT OF STAIRS:

	YES	NO
SLEEP APNEA
DO YOU USE CPAP/BIPAP
SLEEP DIFFICULTIES
SNORING
AWAKENING AT NIGHT
DAYTIME DROWSINESS
OBSERVED APNEA SPELLS
MORNING HEADACHES
VENOUS STASIS
LEG OR ANKLE EDEMA
LEG ULCERATION
PAIN OF ARTHRITIS
IN ANKLES
IN KNEES
IN HIPS
LIMITS ABILITY TO WALK
LIMITS ABILITY TO EXERCISE
LOW BACK PAIN/SCIATICA
LIMITS ABILITY TO WALK
LIMITS ABILITY TO EXERCISE

DIABETES

YES NO
YEAR OF DIAGNOSIS:

	YES	NO
JUVENILE ONSET
GESTATIONAL (PREGNANCY)
ADULT ONSET
DIET CONTROLLED
ORAL MEDICATION
INSULIN
URINARY INCONTINENCE
LEAKING URINE W/ COUGH
LEAKING URINE W/ SNEEZING
LEAKING URINE W/ STRAINING

MIGRAINE

YES NO
FREQUENCY:
DEEP VENOUS THROMBOSIS

YES NO
YEAR OF DIAGNOSIS:

	YES	NO
PULMONARY EMBOLISM
ABDOMINAL WALL HERNIA
INCISIONAL
UMBILICAL

NUMBER OF HERNIA REPAIRS

HAVE YOU EVER HAD/BEEN

	YES	NO
BLOOD TRANSFUSION
HEPATITIS
EXPOSED TO HIV/AIDS
ABUSED INTRAVENOUS DRUGS

PAST MEDICAL HISTORY: PLEASE LIST ALL OTHER MEDICAL CONDITIONS, ILLNESS OR IMPORTANT INFROMATION YOU WOULD LIKE US KNOW ABOUT NOT PREVIOUSLY MENTIONED:
LIST ANY SPECIALIST DOCTORS WHOM YOU SEE AND THE REASON FOR THE VISITS:
PATIENT SIGNATURE: *
DATE

Month Day Year
Date

ACKNOWLEDGEMENT OF PRACTICE POLICIES AND PROCEDURES - GENERAL SURGERY
1. WE WILL COLLECT YOUR OFFICE SPECIALIST CO PAY + CO INSURANCE IF APPLIES AT EACH VISIT. YOUR COPAYMENT/ CONSULTATION FEE CAN TAKE UP TO THREE WEEKS TO CLEAR FROM YOUR BANK.

2. UNLESS TOLD OTHERWISE BY THE DOCTOR, YOU ARE REQUIRED, TO FOLLOW A CERTAIN PRE-SURGERY DIET WHICH CONSISTS OF LIQUIDS FOR ONE WEEK PRIOR TO SURGERY. IF YOU DO NOT ADHERE TO THE LIQUID DIET YOUR SURGERY WILL CANCELED BY DR. JAYASEELAN.

3. YOU WILL BE REQUIRED TO PAY YOUR FEES DEDUCTIBLE, CO-INSURANCE ONE WEEK PRIOR TO SURGERY. THIS AMOUNT VARIES FROM PERSON TO PERSON, DEPENDING ON THE INDIVIDUAL CO-PAYMENT, CO-INSURANCE, DEDUCTIBLE AND HEALTH PLAN. A CANCELLATION FEE WILL BE CHARGED TO YOU IF YOU FAIL TO CANCEL YOUR SURGERY WITHIN 48 HOURS PERIOD.

4. YOU AND YOUR HEALTH INFORMATION ARE PROTECTED BY HIPPA REGULATIONS. WE WILL NOT GIVE ANYONE INFORMATION ABOUT YOU, UNLESS WE HAVE WRITTEN AN AUTHORITY TO DO SO. THE ONLY EXCEPTION IS GIVING INFORMATION TO YOUR INSURANCE COMPANIES AND DISABILITY COMPANIES. IF YOU NEED MORE INFORMATION ON HIPPA LAWS PLEASE ASK RECEPTIONIST.

5. PLEASE BE RESPONSIBLE ABOUT THE INSURANCE INFORMATION YOU PROVIDE TO OUR OFFICE. IF YOUR INSURANCE COMPANY, POLICY, AND OR JOB CHANGES, IT IS YOUR RESPONSIBILITY TO NOTIFY OUR OFFICE. IF YOUR BENEFITS HAVE CHANGED AND YOU DID NOT NOTIFY OUR OFFICE IN WRITING, YOU WILL INCUR ALL MEDICAL COSTS. THIS INCLUDES SURGEON’S FEES, ANESTHESIA FEES, FACILITY FEES, ATTORNEY’S FEES AND ANY COSTS INCLUDED IN RECOVERING THE AMOUNTS DUE TO ALL THAT HAVE PROVIDED CARE FOR YOU.

* THIS IS ONLY AN ESTIMATE UNTIL YOU ARE SEEN IN A CONSULTATION WITH THE SURGEON. AS EACH INDIVIDUAL IS DIFFERENT AND LONGER TIME FOR SURGERY MAY BE REQUIRED.

I (WE) CERTIFY THAT THIS FORM, ALONG WITH ALL OTHER FORMS HAVE BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ THEM OR HAVE HAD THEM READ TO ME AND UNDERSTAND THEIR CONTENTS.
SIGNATURE: *
DATE

Month Day Year
Date

ACKNOWLEDGEMENT OF PRACTICE POLICIES AND PROCEDURES - BARIATRIC SURGERY
1. Once you have been seen by the Physician or Nurse Practioner a pre-determination will be started. This process takes between 4-6 weeks. Please contact your insurance company if it is within this timeframe. Pre Determination with the insurance companies that require additional information will not be sent until all information requested is received. The insurance company cannot make a pre-determination until they have all the needed information.

2. We will collect your office specialist co pay + co insurance if applies at each visit. Your copayment/consultation fee can take up to three weeks to clear from your bank.

3. If you are denied from your insurance company, you may appeal. Our office does not handle that appeal for you. You may utilize www.obesitylaw.com for appeals. We will furnish you with a copy of your charts/file to assist you.

4. Unless told otherwise by the doctor, you are required, to follow a certain pre-surgery diet which consists of
liquids for one week prior to surgery. If you do not adhere to the liquid diet your surgery will canceled by Dr. Jayaseelan.

5. You will be required to pay your fees deductible, co-insurance one week prior to surgery. This amount varies from person to person, depending on the individual co-payment, co-insurance, deductible and health plan. A cancellation fee will be charged to you if you fail to cancel your surgery within 48 hours period.

6. The adjustments needed for your follow up range from $0-$250 depending on your insurance coverage, surgeon, with the exception of self-pay patients. Self-pay patients receive 3 evaluations/adjustments, (fills/unfills), then they are $150 thereafter. New patients that were not banded by Dr. Jayaseelan and are uninsured will be charged $250 for evaluation and or any adjustment necessary you will not be seen unless you supply us with your surgery information and any fills done elsewhere to include OP REPORT AND ADJUSTMENT LOG.

7. You and your health information are protected by HIPPA regulations. We will not give anyone information about you, unless we have written an authority to do so. The only exception is giving information to your insurance companies and disability companies. If you need more information on HIPPA laws please ask receptionist.

8. Please be responsible about the insurance information you provide to our office. If your insurance company, policy, and or job changes, it is your responsibility to notify our office. If your benefits have changed and you did not notify our office in writing, you will incur all medical costs. This includes surgeon’s fees, anesthesia fees, facility fees, attorney’s fees and any costs included in recovering the amounts due to all that have provided care for you.

9. If you self-pay $13,300* (private pay) for the Gastric Sleeve, regular follow up visits in our office are included for the first year following surgery: This is only if you paid the full amount of $5000 to Dr. Jayaseelan. This does not include testing we may refer you to afterwards for diagnostic purposes. Office visits will be $125 thereafter. We will attempt to bill insurance if possible.

10. If you are self-pay $10,360* (private pay) for the Lap Band, you will receive one regular follow up visit in our office for your post-operative visit. 3 evaluations/adjustments, (fills/unfills). This is only if you paid the full amount of $4500 to Dr. Jayaseelan. This does not include testing we may refer you to afterwards for diagnostic purposes. Office visits will be $125 thereafter. We will attempt to bill insurance if possible.

* This is only an estimate until you are seen in a consultation with the surgeon. As each individual is dif ferent and longer time for surgery may be required.

I (we) certify that this form, along with all other forms have been fully explained to me, that I (we) have read
them or have had them read to me and understand their contents.
SIGNATURE: *
DATE

Month Day Year
Date

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
I HEREBY ACKNOWLEDGE THAT I HAVE BEEN PRESENTED WITH A COPY OF NIRMAL S. JAYASEELAN, M.D. NOTICE OF PRIVACY PRACTICES.
PATIENT SIGNATURE: *
DATE

Month Day Year
Date
RELATIONSHIP:

SELF PARENT GUARDIAN
IN ORDER TO PROTECT YOUR PRIVACY, WE ASK THAT YOU COMPLETE THE FOLLOWING SECTION, WHICH WILL ENABLE US TO BETTER SERVE YOU IN THE FUTURE. PLEASE WRITE YOUR INITIALS BESIDE EACH STATEMENT. WE ALSO ASK THAT YOU ENTER THE NAME OF EACH PERSON YOU WOULD LIKE TO HAVE ACCESS TO YOUR ACCOUNT (THIS INCLUDES YOUR SPOUSE). ALSO, PLEASE SIGN AND DATE THE BOTTOM OF THIS FORM. YOU MAY UPDATE THIS INFORMATION AT ANY TIME. THANK YOU FOR YOUR COOPERATION.
PLEASE TICK

I AUTHORIZE THE OFFICE OF NIRMAL S. JAYASEELAN, M.D. TO LEAVE INFORMATION REGARDING MY APPOINTMENTS AND/OR ACCOUNT INFORMATION ON MY ANSWERING MACHINE/VOICEMAIL/EMAIL ADDRESS AT HOME/WORK/CELL. I AUTHORIZE THE OFFICE OF NIRMAL S. JAYASEELAN, M.D. TO LEAVE INFORMATION REGARDING MY LABS AND TEST RESULTS THAT ARE NORMAL, ON MY ANSWERING MACHINE/VOICEMAIL/EMAIL ADDRESS. I AUTHORIZE THE OFFICE OF NIRMAL S. JAYASEELAN, M.D. TO SPEAK TO THE FOLLOWING PEOPLE REGARDING MY INSURANCE COVERAGE, FINANCIAL ACCOUNT, APPOINTMENTS, LAB AND TEST RESULTS, AND COURSE OF TREATMENT:
NAME
RELATIONSHIP
DATE OF BIRTH

Month Day Year
Date
NAME
RELATIONSHIP
DATE OF BIRTH

Month Day Year
Date
NAME
RELATIONSHIP
DATE OF BIRTH

Month Day Year
Date

ACKNOWLEDGEMENT OF PRACTICE POLICIES AND PROCEDURES - GASTRIC BALLOON
1. UNLESS TOLD OTHERWISE BY THE DOCTOR, YOU ARE REQUIRED, TO FOLLOW A CERTAIN DIET WHICH CONSISTS OF LIQUIDS NIGHT PRIOR TO SURGERY. IF YOU DO NOT ADHERE TO THE LIQUID DIET YOUR PROCEDURE WILL BE CANCELED BY DR. JAYASEELAN.

2. YOU AND YOUR HEALTH INFORMATION ARE PROTECTED BY HIPPA REGULATIONS. WE WILL NOT GIVE ANYONE INFORMATION ABOUT YOU, UNLESS WE HAVE WRITTEN AN AUTHORITY TO DO SO. IF YOU NEED MORE INFORMATION ON HIPPA LAWS PLEASE ASK RECEPTIONIST.

3. A CANCELLATION FEE WILL BE CHARGED TO YOU IF YOU FAIL TO CANCEL YOUR PROCEDURE WITHIN 48 HOURS PERIOD.

I (WE) CERTIFY THAT THIS FORM, ALONG WITH ALL OTHER FORMS HAVE BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ THEM OR HAVE HAD THEM READ TO ME AND UNDERSTAND THEIR CONTENTS
SIGNATURE: *
DATE

Month Day Year
Date

SBT
Should be Empty:

NEW PATIENT INFORMATION