Roper Rd Prof. Centre
5341 75 Street Edmonton AB
T6E 0W4
_____
10131 102 Ave
Grande Prairie AB
T8V 4P4
Troppman Prosthetics Patient Information Intake Form
Personal:1. Date of Entry: / Date / Month / Year
2. Last Name:
3. First Name:
4. Date of Birth: / Date / Month / Year
5. Amputation Level: / Lower Extremity: DFDChoose from the drop down menuNot ApplicableLLTT Lower Left TransTibial (below knee)LRTT Lower Right TransTibial (below knee)BLTT Bilateral Transtibial (below knee)LLTF Lower Left TransFemoral above knee)LRTF Lower Right TransFemoral (above knee)BLTF Bilateral TransFemoral (below knee)Right SymesLeft SymesLeft RotationplastyRight RotationplastyOther
Other notes: / Upper Extremity:
Choose from the drop down menuNot applicableULPH Upper Left Partial HandURPH Upper Right Partial HandULTR Upper Left TransRadial (below elbow)URTR Upper Right TransRadial (below elbow)ULTH Upper Left TransHumeral (above elbow)URTH Upper Right TransHumeral (above elbow)Left Finger Prosthesis (specify in notes below belRight Finger Prosthesis (specify in notes belowBLTR Bilateral TransRadialBLTH Bilateral TransHumeralLeft Shoulder DisarticulationRight Shoulder DisarticulationOther
Other notes:
6. Date of Amputation: / Date / Month / Year
7. Cause of Amputation:
8. Street Address:
9. City and Postal Code:
10. Contact Phone#:
11. Emergency Contact:
12. Emergency Phone #:
13. Email ID:
14. Weight in lbs:
15. Height : / Choose from the drop down menu01234567 feet / Choose from the drop down menu0"1"2"3"4"5"6"7"8"9"10"11"12" inches
16. Purpose of this appointment: / Choose one from the drop down menuConsultInitial EvaluationTransfer of CareI need Supplies Other
17. How did you hear about us?
Financial:
18. Alberta Health Card # : / Format: 12345-1234
19. Primary Funding Source: / Choose from the drop down menuAADL (Alberta Aids to Daily Living)AISH Assured Income for Severely HandicappedChampsInterim Federal HealthICBCNIHBPharmacarePrivate Insurance Veteran AffairsWar Amps
20. Secondary Funding Source: / Choose from the drop down menuAADL (Alberta Aids to Daily Living)AISH Assured Income for Severely HandicappedChampsInterim Federal HealthICBCNIHBPharmacarePrivate Insurance Veteran AffairsWar Amps / (add further info in additional comments below
21. Do you have a Treaty status? / Yes (complete field 22, if yes) / No Skip to field 24
22. Treaty #:
23. Are you a WCB patient? / Yes (complete 24 and 25, If yes) Choose from the drop down menuAlbertaBritish ColumbiaNWTOntarioYukonOther / No Skip to field 26
24. WCB Claim # :
25. Case Manager: / Name: / Phone#:
Medical:
26. Have you had a prosthesis made elsewhere: / Yes (complete 27 and 28) / No Skip to field 29
27. If you answered Yes to field 26, when
was your prosthesis made: / Date / Month / Year
28. If you answered Yes to field 26, then where
was your prosthesis made (Name of the Clinic):
29. List any major illnesses or hospitalizations:
30. Have you been treated for any
health conditions that we should know about:
31. What medications or drugs are you taking:
32. Are you experiencing any of the following:
Please check all that apply: / Anxiety Alcoholism Allergies Anger
Depression Communication Issues Depression
Drug Addiction Diabetes Eating Disorder
HIV positive Infections
Post Traumatic Stress Disorder Recent Weight Change Stress MRSA VRE
33. Activity Level: / Choose from the drop down menuExcercise regularlyI have functional limitations when walkingI have functional limitations-when taking stairsOther
34. Indicate functional limitations with:
Please check all that apply: / Walking Stairs
Endurance/Distance Upper Extremity Function
35. Name of Surgeon:
36. Name of Physiotherapist:
37. Personal Goals for use of Prosthesis:
38. Additional comments:
Troppman Prosthetic Ltd. Personal Information Consent Form
We are committed to protecting the privacy of our patients’ personal information and utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.
We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers and e-mail addresses (Collectively referred to as “Contact Information”). Contact Information is collected and used for the following purposes:
· To open and update patient file.
· To invoice patients for prosthetic services, to process credit card payments, or to collect unpaid accounts.
· To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
· To send reminders to patients concerning the need for further prosthetic examination or treatment.
· To send patients informational material about our prosthetic practice.
Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of prosthetic treatment or has asked us to submit a claim on the patient’s behalf.
Financial information may be collected in order to make arrangements for the payment of prosthetic services. We collect information from our patients about their health history, their family health history, physical condition, and prosthetic treatments (Collectively referred to as “Medical Information”). Medical Information is collected and used for the purpose of diagnosing prosthetic condition and providing prosthetic treatment.
Patients’ Medical Information disclosed:
To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of prosthetic treatment or has asked us to submit a claim on the patient’s behalf.
To other health care professionals such a physicians if the patient, with their consent, has referred by us to other health care professional for either a second opinion or treatment.
If we are ever considering selling all or part of our prosthetic practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.
Certified Prosthetists are regulated by the Canadian Board of Certification of Prosthetists and Orthotists which may inspect our records and interview our staff as part of its regulatory activity in the public interest.
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Patient Code of Conduct
In an effort to provide a safe and healthy environment for staff, patients, visitors and their families, Troppman Prosthetics Ltd. expects patients, visitors and accompanying family members to refrain from unacceptable behaviors that are disruptive or pose a threat to the rights or safety of other patients and staff.
The following behaviors are prohibited:
· Possession of any weapons
· Physical or verbal threats
· Throwing objects
· Climbing on furniture in waiting area and or equipment in the fitting rooms
· Making verbal threats and or intentionally harming another individual or damaging property
· Attempting to harass or intimidate another individual
· Making harassing, offensive or intimidating statements or threats of any kind though phone
calls, letters, voicemail, email, or any other forms of written or electronic communication
· Racial or cultural slurs or other derogatory remarks associated with, but not limited to race,
language, gender etc.
If you are subjected to any of these behaviors or witness inappropriate behavior, please report to any staff member. Violators are subject to removal from the facility and/or discharge from the clinic.
Adults are expected to supervise children in their care.
By signing this form I hereby consent to the collection, use and disclosure of my personal information as set out above. I also agree to the Troppman Prosthetic Ltd. Patient Code of Conduct.
Print Name Signature Date
Troppman Prosthetics Ltd. No-Show Policy
There is a $25 no-show/late-cancellation fee. All appointments must be cancelled by within 24 hours of scheduled appointments, to avoid no-show or late-cancellation fees. Insurance will not cover these charges.
Print Name Signature Date
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