2777 Mile High Stadium CircleDenver, CO 80211

Ph: 303-825-8822 Fax: 303-825-4022www.TUCC.com

Brett B. Abernathy, M.D., F.A.C.S. Ben Carpenter, M.D.Julien E. Dagenais, M.D. Christopher J. Dru, M.D.Eric T. Gross, M.D.Richard K. Heppe, M.D.Elias L. Hsu, M.D.Marklyn J. Jones, M.D. Lawrence L. Karsh, M.D., F.A.C.S. Donald J. May, M.D.Juan Montoya, M.D.

Ferdinand J. Mueller Jr., M.D. Alexander C. Philpott, M.D. David C. Ragan, M.D.Stephen R. Ruyle, M.D., F.A.C.S. Brian R. Smith, M.D.Carsten M. Sorensen, M.D.John Tillett, M.D., F.A.C.S. Stephen Bales, R.N., N.P Jennifer Gomez, MMS, PA-C Shelly Shadrick, P.A-C.Lisa Zwiers, P.A-C.

_____ INSURANCE CARD(S) AND COPAYMENT (if applicable).

_____ COMPLETED REGISTRATION AND MEDICAL HISTORY FORMS. Do NOT mail them to us. Please bring them with you to

your appointment.

_____ REFERRAL INFORMATION from your primary care physician (if applicable) PLEASE obtain the referral PRIOR to your

appointment. LACK OF REFERRAL may require rescheduling of your appointment.

_____ LAB REPORTS (if not drawn at TUCC) to include:

Urinalyses, urine cultures, PSA's [current and prior], kidney function tests, 24 hour urine tests and

Semen analysis for fertility appointments.

_____ RADIOLOGIC FILMS AND REPORTS if not performed at TUCC which may include:

IVP's, Renal Ultrasound, Testicular Ultrasound, CT [Urologic] Bone Scans, KUB'S) If you are unable to

obtain your reports please call our office.

_____ BRING YOUR LIST OF MEDICATIONS, HERBALS AND SUPPLEMENTS with doses and how often you take them.

_____ Please be prepared to give a urine sample at the time of your visit.

_____ You are scheduled with Dr. _____________________________________________________________________

On ______________________________________________ _ at _________________am pm

_____Please arrive 15 minutes prior to your appointment.

_____ Please arrive 30 minutes prior to your appointment.

We ask that if you are unable to make this appointment that you call us to cancel or reschedule. If you do not come

for the appointment and do not call to cancel or reschedule we will not make another appointment for you.

We will bill your insurance carrier(s) if we are contracted with them. We will also bill Medicare and Medicaid. If we are notcontracted with your insurance we ask that you pay for your care at the time of service. We accept checks, cash, Visa,MasterCard, and Discover. If you have any questions about your bill please contact our billing office. There is a possibilityyou will receive multiple bills from your treatment at TUCC including Colorado Imaging Associates which reads our x-rays,UniPath which reads our biopsy slides, the Urology Surgery Center (USCC) which is the ambulatory surgery facility in thebuilding where we do our cystoscopies and surgeries, Physician Anesthesia Services which are the anesthesiologists in thesurgery center, and outside hospital bills for any treatments we perform at these facilities. You may also receive a bill fromLabCorp or Quest for labs we send out to be processed. If you have questions about the bills you may receive from theseother providers, do not hesitate to call their billing offices.

We wish to welcome you as a new patient to The Urology Center of Colorado. We provide a range of comprehensive services toour patients and we want to thank you for choosing TUCC to support you in your health care needs. To best meet your medicalneeds, you need to furnish the following item(s) upon arrival at our office:

2777 Mile High Stadium Circle

Denver, CO 80211Ph: 303-825-8822 Fax: 303-825-4022

www.TUCC.com

Brett B. Abernathy, M.D., F.A.C.S. Eric T. Gross, M.D.Ben Carpenter, M.D.Julien E. Dagenais, M.D. Christopher J. Dru, M.D.Richard K. Heppe, M.D.Elias L. Hsu, M.D.Marklyn J. Jones, M.D. Lawrence L. Karsh, M.D., F.A.C.S. Donald J. May, M.D.Juan Montoya, M.D.

Ferdinand J. Mueller Jr., M.D. Alexander C. Philpott, M.D. David C. Ragan, M.D.Stephen R. Ruyle, M.D., F.A.C.S. Brian R. Smith, M.D.Carsten M. Sorensen, M.D.John Tillett, M.D., F.A.C.S. Stephen Bales, R.N., N.P Jennifer Gomez, MMS, P.A-CShelly Shadrick, P.A-CLisa Zwiers, P.A-C.

Patient Information

Name: ___________________________________________________________ Sex: M / F Today’s Date: ___________________

Social Security: ________________________________ Date of Birth: ______________________ Marital Status: M / S / D / W

Street Address: ____________________________________________________________________________________________________

Street, PO box City State Zip

Contact Phone Numbers: ______________________________ ______________________________ _____________________________Home Work Cell:

Primary:_____________________________ (H/W/C) Company name: __________________________________

Secondary: __________________________(H/W/C) Employment Status: [] Full-time [] Part-time

Alternate: ___________________________(H/W/C) Retired: [] Y [] N Unemployed: [] Y [] N

E-mail Address: ______________________________________________ (Used to send you a Patient Portal invitation)

Additional Information

Preferred Language: _________________________ __________1. Race: [] White [] Black or African American [] American Indian [] Alaska Native [] Native Hawaiian or Other Pacific Islander [] Asian

[] Multiracial

2. Ethnicity: [] Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South [] Central American [] other Spanish culture/origin)

[] Non Hispanic or Latino

Referring Physician Name: ____________________________________ Referring Physician Phone #:___________________________

Primary Care Physician Name #: ________________________________ Primary Care Physician Phone #: ________________________

Emergency Contact: ________________________ Relationship to you: ____________Emergency Phone number: _________________

Insured Information

Primary Insurance Company: ____________________________________________________________________________Primary Insured Name: ___________________________________Insured Relationship to patient: ____________________

(Are you the policy holder or is your spouse/parent) (Parent, Legal Guardian, Spouse

Insured Phone: ____________________________________ Insured Social Security Number: _______________________

Insured Date of Birth:________________________________ Insured Employer: __________________________________

Insurance Claims Address:_______________________________________________________________________________

Insurance ID Number: _______________________________ Group Number: _____________________________________

Secondary Insurance Company: __________________________________________________________________________

Secondary Insured Name: ____________________________ Insured Relationship to patient: _________________________(Are you the policy holder or is your spouse/parent) (Parent, Legal Guardian, Spouse)

Insured Date of Birth: ___________________ Insurance Claims address: _________________________________________Insurance ID Number: _______________________________ Group Number: ___________________________________

NSURANCE AUTHORIZATION AND ASSIGNMENTI hereby authorize The Urology Center of Colorado to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to thephysician all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance,all collection costs should this account be assigned for collection. I accept and understand the responsibility of notifying TUCC of any requirement by myinsurance company of pre-authorization prior to any hospital admission or surgical procedure, whether done in office or in hospital. Iunderstand that it is also my responsibility to verify that a pre-authorization has been completed prior to any hospital admission or surgical procedure. I also

understand that if I fail to obtain a referral, if it’s necessary, I will be responsible for the charges.

Patient Signature: __________________________________________________________________ Date: ______________________

THE UROLOGY CENTER OF COLORADOPlease Print

_________________________________________________________________________________________________________

Patient Name Date of Birth Height Weight_______________________________________________________________________________________________Referring Physician Reason for Visit Today’s Date

PERSONAL MEDICAL HISTORY: Please circle any condition(s) that apply.

CARDIAC RESPIRATORY DIGESTIVEENDOCRINE& EYES

BLOOD &IMMUNE

MUSCULO-SKELETAL

NEUROLOGICINFECTIOUSDISEASE

Valve Surgery Asthma GERD Diabetes Cirrhosis Total JointReplacement

Stroke HIV/AIDS

Heart Attack Clots in lungs Irritable BowelSyndrome

Gout Clots in arms orlegs (DVT)

Osteoporosis MultipleSclerosis (MS)

Hepatitis

RheumaticFever

COPD Peptic Ulcers Hypothyroid(underactive)

Leukemia Osteoarthritis Spina Bifida MRSA

High BloodPressure

Sleep Apnea UlcerativeColitis

Glaucoma RheumatoidArthritis

Fibromyalgia Parkinson’sDisease

CongestiveHeart Failure

Emphysema Diverticulitis Hyperthyroid(overactive)

Scleroderma Depression

AtrialFibrillation

Crohn’sDisease

Lymphoma Anxiety

HighCholesterol

Lupus Seizures

Defibrillator Alzheimer’sPacemaker

Heart Stents

Any Cancer(s): No ____ Yes If yes, what type? ____________________________________________________

Any Radiation: No ____ Yes ____ Site on body ____________________________________________________

Do you take any antibiotics prior to a procedure? No ___Yes ___ If yes, what & when?___________________

Allergies: No ___ Yes ___ Please Circle items you are allergic to: Penicillin, Ampicillin, Sulfa, Bactrim,

Macrodantin, Levaquin, Iodine, Tape, Latex.

Other allergies: _____________________________________________________________________________

YOUR MEDICATIONS

Current Local Pharmacy Name and Phone # City Cross Streets

Prescribed Medications Supplements, Herbals, Over-the-Counter Products

Name Strength When Name Strength When

The Urology Center of Colorado Original: [1993] [mlr]Revision: [10.6.2017] [mlr] (12.12.2017] [mlr] Reviewed: [08/21/2018] [lp]

Please turn this page over

THE UROLOGY CENTER OF COLORADOPlease Print

Patient Name Date of Birth

SURGERIES Type of surgery and approximate date

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

___________________________________________________________________________

PERSONAL GENITOURINARY HISTORY None ____ Please circle any that apply:Kidney Cancer Kidney Stones Prostate InfectionsProstate Cancer Ureter Stones Prostate EnlargementBladder Cancer Bladder Stones InfertilityTesticular Cancer Bladder Infections Kidney FailureDo you leak urine when you cough or exercise? No ___ Yes ____ if yes, pads per day?Do you leak urine when you feel an urge to urinate but cannot get to the bathroom in time?Do you have problems achieving or maintaining an erection? ____________________________

FAMILY MEDICAL HISTORY (Blood relatives only): Do any of your family members have any of the following conditions?CONDITION YES NO Relationship to you

Kidney / Bladder / ProstateCancer?

Kidney problems / stones

Blood pressure problems

Bleeding problems

Diabetes

Asthma / Breathing problems

Reaction to anesthesia

Cardiac problems

** Parents’ current age if still alive M _______ F_______If parents’ are deceased, age and cause of death M__________________________ F __________________________

SOCIAL HISTORYDo you use tobacco? No _____ Yes _____ If yes, packs per day

Have you stopped using tobacco? No _____ Yes _____ If yes, how long did you smoke? What year did you quit?

Do you use alcohol? No _____ Yes _____ If yes, how often and how much?

Do you have a history of sexually transmitted diseases? No _____ Yes _____ If yes, what?

Do you use recreational drugs? No ____ Yes ______ If yes, what kind, how often ?

Working? No ____ Yes ____ Retired? No ____ Yes ____ What is/was your occupation?

Married/Single/ Life Partner? # of children?

WOMEN only: # of pregnancies? Are you currently pregnant

REVIEW OF SYMPTOMSCONSTITUTIONAL MUSCULOSKELETAL Psychological CARDIAC DIGESTIVE

Fever Chills Headache Weight Loss Chronic Fatigue Sleep Disorder

Neck Problems Joint Pain

Nervousness Anxiety Depression

Chest Pain /Angina

Palpitations /Heart Racing

Nausea / Vomiting Constipation Diarrhea

RESPIRATORY ENDOCRINE BLOOD / IMMUNE NEUROLOGIC

Wheezing Shortness of

Breath Productive Cough Bloody Cough

Blurred Vision Ear infections Sore Throat Sinus problem

Tired / Sluggish Excessive Thirst

Swollen glands Blood clotting

Numbness andTingling

Loss of strength

Loss of sensation

Other Symptoms:The Urology Center of ColoradoOriginal: [1993] [mlr]Revision: [10.6.2017] [mlr] (12.12.2017] [mlr] Reviewed [08/21/2018] [lp ] Revised [9/21/18 [lp] Provider Initials: ___________

SKIN

Rash, Skin

Breakdown Lesions

EENT

2777 Mile High Stadium Circle Denver, CO 80211

Ph: 303-825-8822 Fax: 303-825-4022www.TUCC.com

How Did You Hear About TUCC?

Check all that apply

___ Referral from primary care physician - Physician Name:_____________________

___ Referral from friend or family member

___ TUCC website

___ The Center for Men’s Health at TUCC website

___ Hospital – Please list facility name: ______________________________________

___ Advertisement in 5280 Health Magazine

___ Advertisement in 2018 Colorado Health & Wellness Magazine

___ Advertisement on Internet search engine (Google, Bing, Yahoo, etc.)

___ Listing on online review site (Google, Facebook, Healthgrades, Yelp, etc.)

___ Digital advertisement promoting prostate cancer care at TUCC

___ TUCC clinical trial advertisement

___ News story

___ Dr. Mark Moyad’s Annual Nutrition Update

___ The Blue Shoe Run for Prostate Cancer

___ Other, Please describe: _____________________________________________

Email Address:

________________________________________________________ (Please include

your email address if you are interested in receiving updates from TUCC regarding

patient education events.)

The Urology Center of ColoradoOriginal:Revised: : [12/17/14] [mlr] [10/11/2017] [mlr] [6/27/2018] [mlr] [7.23.2018] [mlr] [7.23.2018] [mlr] [8.15.2018] [mlr] Reviewed: [10/10/2018] [ lp]