TRMC’s 8thAnnual PhysicianAPP

Health ScreeningPre-Registration Forms

Thursday, September 29, 2016

Located the TRMC Radiology Department

Please complete all pages of the pre-registration forms below. (This will save you time on the day of the screenings).You may send the completed forms by email, fax or place in an envelope in the Outreach & DevelopmentDepartment mailbox in the hospital mail room.

To submit electronically:

  1. Go to File, (top left corner of the screen)
  2. Save & Send, (approx. 10 tabs down)
  3. Send As An Attachment (far right column)
  4. and email it to me at

Once the forms have been received, you will receive an email confirmation. If you do not receive a confirmation, then your forms did not go through.

For more information contact:

Monica MorrisACCOUNT #______(LEAVE BLANK)

229-353-6312 Office, 229-353-6317 FaxAccount # to be generated by Hospital Registration on the day of screening

Please print and complete all boxes

Name:
Legal Name
Home Address:
(Last Four Digits) Social Security Number:
(Required for system identification) / (last four digits only)
Date of Birth:
Age:
Race:
Sex (Male/Female):
Language:
Title (ex: MD, DO, DPM, PA, NP, CRNA):
Home Phone Number:
Additional comments:

PAGE 1 of 5

CONSENT TO MEDICAL SCREENING

In consideration of medical examination and screening which may be provided to me during the Medical Staff Screening sponsored by the Tift County Hospital Authority d/b/a Tift Regional Medical Center (hereinafter “Tift Regional”), I do hereby agree and consent as follows:

  1. CONSENT AND EXAMINATION AUTHORIZATION.

I do hereby consent to and authorize the administration of the following examination and screening: Chest X-Ray, EKG, Wellness Profile (CBC, Bio profile, Lipid Profile, TSH, PSA (for men over 50), B/P, Weight, Height, BMI, and Annual Screening Mammogram (for women over 40).

2.EXAMINATION AND SCREEN IS NOT COMPLETE MEDICAL EXAMINATION. I recognize and accept all risks associated with the examination and screening services provided. I understand that the examination and screening is only an examination and screen for abnormalities and does not constitute a complete medical examination or diagnosis. For a diagnosis of a medical problem, I must see a physician for a complete medical examination. Tift Regional is providing screening mammograms, any follow up such as spot images or ultrasounds are the patient’s responsibility.

3.RECORDS OF THE EXAMINATION AND SCREEN. I recognize and understand that the results of the screening will be mailed in a confidential envelope to my office or other address of choice as indicated below. Tift Regional will also keep a copy of the results in a confidential record to be stored in the hospital’s electronic medical record.

4.UNDERSTANDING OF CONSENT. I certify by execution of this Consent that I have read and understand the above conditions of examination and screening and that I am legally authorized to execute this Consent to Medical Examination and Screening on my behalf.

I AM AWARE THAT THE PRACTICE OF MEDICINE IS NOT AN EXACT SCIENCE AND ACKNOWLEDGE THAT NO GUARANTEES HAVE BEEN MADE TO ME AS TO RESULTS OF EXAMINATION OR SCREENS.

PATIENT NAME:

(Print Name) (Sign Name)

DATE:

FOR PHYSICIAN SCREENING ON SEPTEMBER29, 2016

WITNESS:

PLEASE SEND THE RESULTS IN A CONFIDENTIAL ENVELOPE TO:

(Check one location)(Print Address)

MY OFFICE ADDRESS: ______

______

HOME ADDRESS:______

______

______Hospital Mailbox

* Please check the screenings you wish to participate in under the TEST REQUESTED column *

patient sticker here

PROVIDER

CHECK-OFF FORM

Physician & APP Health Screenings

September 29, 2016

Wellness Profile: / TEST
REQUESTED / Completed / Declined / Completed
By (Initials) / Results
Received
Flu Vaccine / N/A
TB Skin Test
*Wellness Profile
PSA
Only for men >50 y/o
Hemoglobin A1 C
only if >150 / Lab only Abnormal values / N/A
Urinalysis
EKG
Chest X-ray
**Screening Mammogram

*Wellness Profile Includes: CBC, Bio profile, Lipid Profile, TSH

**Screening Mammogram: Screening mammograms are for women 40+ years of age and who are asymptomatic and needs a routine annual exam and these are done one year apart. Participants that need a diagnostic mammogram will not be part of this screening.

SEASONAL INFLUENZA VACCINE CONSENT FORM

2016-2017

Have you received the influenza vaccine in the past? Y N

If yes, when was your last influenza shot? ______

Have you had a reaction to the influenza vaccine in the past? Y N

Have you had any fever or recent illness? Y N

If yes, then explain. ______

Are you allergic to eggs? Y N

Do you have any allergies? Y N

If yes, please list: ______

I have read the Centers for Disease Control (CDC) Vaccine Information Statement “Influenza Vaccine: What You Need to Know” and have had an opportunity to ask questions. I understand the risks and benefits of the vaccine, and consent to vaccination with Inactivated Influenza vaccine. I agree to stay for a 15 minute observation period after my injection.

NAME: (Please Print Full Legal Name) ______

AGE: ______DATE OF BIRTH: ______

MOTHER’S MAIDEN LAST NAME: ______

PRESENT ADDRESS: ______

CITY______ZIP______

Previous Address if changed within 1 year: ______

SIGNATURE: ______DATE: ______

*GRITS Purpose – Please List any other name used in past years.______

FOR EMPLOYEE HEALTH USE ONLY:

Person verifying consent form and giving vaccine: ______

Lot#______Exp. Date: ______Site: LEFT DELTOID RIGHT DELTOID

GRITS Entered:

TB SKIN TEST READING

NAME: ______DATE:

1. Have you ever had a positive skin test? Y [ ] N [ ]

2. If you have had a positive TST, do you have any of the following?

Cough lasting > 3 weeks?Y [ ] N [ ]

Loss of appetite? Y [ ] N [ ]

Unexplained weight loss? Y [ ] N [ ]

Night sweats? Y [ ] N [ ]

Bloody sputum? Y [ ] N [ ]

Hoarseness? Y [ ] N [ ]

Fever? Y [ ] N [ ]

Fatigue? Y [ ] N [ ]

Chest pain? Y [ ] N [ ]

3. Have you had latent TB infection therapy (preventive therapy with INH)? Y [ ] N [ ]

If yes, then when ______(year)? Did you complete the therapy? Y [ ] N [ ]

4. Have you ever received a BCG Vaccine? Y [ ] N [ ]

5. Have you taken steroid medication or received alive virus vaccine in the last month? Y [ ] N [ ]

SIGNATURE: ______

The tuberculin skin test must be read within 48 to 72 hours. Anyone who is certified to read the Mantoux (TB skin test) can interpret and record the results. If the test is not read within the 48 to 72 hour time frame, the test must be repeated. If there is any swelling with redness where the test was given, it might be considered a positive test. If you think that your test might be positive, return to the Employee Health Department promptly. If the test is positive, do not become scared or alarmed. A positive test merely means that you have been exposed to someone who had Tuberculosis, not that you have an actual case of TB.

Date Given: Lot / Exp #:

Given by:

Site: (circle)Left ForearmRight Forearm

Date Evaluated:______Negative ○ Positive○Size:______x ______mm

Read by:

Follow up (if any): ______

Health Screening Consent FormPage 1 of 5