Eastern Shore Neurology & Pain Center

R.M. Tarabein, M.D.

Welcome!

Patient's Name: Last name, First name, Middle name or initial-MR#
Date: On behalf of all of us, thank you for choosing Eastern Shore Neurology & Pain Center for your medical needs. We want your first as well as all subsequent visits to go as smoothly as possible. If you find yourself waiting, please rest assured that Dr. Tarabein & his staff will give you equal attention and time. We would rather you have a short wait than to feel rushed and not attended to thoroughly. Please be advised that the information you'll provide us is vital and very important. Should you have any questions at any time or need help in completing this form or paperwork, please do not hesitate to ask our friendly staff. We advise that you visit our website at www.easternshoreneurology.com so that you could familiarize yourself with our office policies, learn how to request a medication refill or just ask a question, and more, all online.
Please tell us your main reason of your visit to see Dr. Tarabein.
Please list all medications you are now taking, indicating dosage, frequency and prescribing physician.
	Please check here if you are not presently taking meds.
Please list all allergies if any.
	Please check here if you have no allergies.
Anything else you feel we should know?
Name: Last name, First name, Middle name or initial-MR#
Date: Financial Responsibility I, understand, in consideration of medical services to be rendered at Eastern Shore Neurology Clinic, Inc. by Rassan M. Tarabein, M.D. and/or his staff to the above named patient, does hereby agree to pay to Rassan M. Tarabeinm M.D. on demand for said services and related charges on behalf of such patient. If payment, or arrangements for payment as approved by Easter Shore Neurology Clinic, Inc. are not made within thirty (30) days of demand, the account may be turned over for collection. I undersigned, agree to pay up to 33% collection fees, not including attorneys fees, and sahll also pay interest at the rate of 1% per month commencing ninety (90) days after demand for payment has been made on any unpaid amounts. Authorization to Obtain or Release Medical Information Any hospital and attending physicians and other medical providers are hereby authorozed to release to Rassan M. Tarabein, M.D. and/or Easter Shore Neurology Clinic, Inc. any medical records required in the processing of applications for financial coverage or insurance benefits for all services rendered to the patient. Further, I hereby authorize Rassan M. Tarabein, M.D. and/or Easter Shore Neurology Clinic, Inc. to release any records and information generated by aster Shore Neurology Clinic, Inc. and it's related health care providers and all records and information obtained from outside licensed physician, hospital, clinic and any other medically related facilities to any other party as may be necessary for purposes of subrogation and/or direct recover. Release and Assignment of Insurance Benefits I hereby authorize direct payment of medical and surgical benefits to Rassan M. Tarabein, M.D. and/or Easter Shore Neurology Clinic, Inc. I authorize the release of my medical information necessary to process my insurance claims. I agree that this authorization will continue such authorization is revoked by me in writing. I agree that a photocopy of this form may be used in lieu of the original. I understand that I am personally responsible to Rassan M. Tarabein, M.D. for all charges for such services. Authorization to Obtain Credit Report I hereby authorize Easter Shore Neurology Clinic, Inc. and/or Rassan M. Tarabein, M.D. to obtain a credit report on me. This authorization shall continue in full force and effect so long as any charges and fees owed by me to Easter Shore Neurology Clinic, Inc. and/or Rassan M. Tarabein, M.D. remain unpaid. THIS AUTHORIZATION GRANTS VALID, LEGAL AND ENFORCEABLE RIGHTS TO EASTERN SHORE NEUROLOGY CLINIC, INC. AND/OR RASSAN M. TARABEIN, M.D. YOU SHOULD READ THIS DOCUMENT CAREFUL PRIOR TO SIGNING IT. BY YOUR SIGNATURE BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND AGREE TO BE BOUND BY ITS TERMS AND CONDITION.
Signature: X (will sign in office)
I qualify to sign because I am: Eastern Shore Neurology & Pain Center R.M. Tarabein, M.D. www.easternshoreneurology.com AGREEMENT FOR CONTROLLED SUBSTANCE PRESCRIPTIONS	The above named patient The above named patient's legal guardian
Name: Last name, First name, Middle name or initial-MR#
Date: Controlled substance medications (i.e. Opioids, tranquilizers, and barbiturates) are very useful, yet; they have high potential for misuse, and are therefore closely controlled by our office, as well as the local, state and federal government. They are intended to relieve pain to improve function and/or ability to work, and NOT simply to feel good. Because my physician is prescribing such medication for me to help manage my pain, I agree to the following conditions: I am responsible for my controlled substance medications. If the prescription of medication is lost, misplaced, or stolen, or if I use it up sooner than prescribed, I understand that it will not be replaced. I will not request or accept controlled substances medication from any other physician or individual while while I am receiving such medication from my physician while under his/her care. Besides being illegal to do so, it many endanger my health. The only exception is when it is prescribed while I am admitted into a hospital. Refills of controlled substance medication: Will be made only during regular office hours. Monday thru Friday, in person, once each month during a scheduled time. Refills will not be made at night, on holidays, or weekends. Will not be made if I "run out early" or "lose a prescription" or "spill or misplace my medication". I am responsible for taking my prescribed medication in the dose and frewuency which Dr. Tarabein has instructed me. Will not be considered as "emergency", such as on Friday afternoon because I suddenly realize I will "run out tomorrow". I will call my nurse at least twenty-four (24) business hours before my prescription runs out. It may be deemed necessary by my doctor for me to see a medication abuse specialist at any time while I am receiving controlled substances. I understand that if I do not attend this appointment, my medications may not be continued or refilled beyond a tapering dose to completion. I understand that if this specialist feels I am at risk for psychological dependence (addiction), my medications will no longer be refilled until I successfully complete a controlled medicine rehabilitation program I agree to comply with random urine, blood, or breath testing to document the proper use of my medications and to confirm my compliance. I understand that I should not be driving a motor vehicle (or operating hazardous machinery) at times while taking controlled substances, and that it is my responsibility to comply with the city, state & federal laws. I understand that if I violate any of the above conditions, my controlled substance prescriptions and/or treatment may be ended immediately. If the violation involves obtaining controlled substances from another individual, as described above, or the concomitant use of non-prescribed illicit (illegal) drugs, I may also be reported to other physicians, medical facilities, and other appropriate authorities. I understand that the main treatment goal is to improve my ability to function and/or work and/or reduce damage. In consideration of that goal and the fact that I am given potent medication to help me reach that goal, I agree to help myself by following better health habits: exercise, weight control, avoiding the use of tobacco and alcohol. I must also comply with the treatment plan as prescribed by my doctor. I understand that only through following a healthier lifestyle could I hope to have the most positive outcome from my treatment. I understand that the long-term advantages of chronic Opioids use have yet to be scientifically determined and that treatment may change throughout my time as a patient. I understand, accept, and agree with the fact that there may still be unknown risks associated with long-term use of controlled substances and that my physician will advise my as knowledge and training advances and will make appropriate treatment changes. I have been fully informed by Dr. Tarabein and his staff regarding the rare, yet still possible psychological dependence (addiction) of a controlled substance. I know that some persons may develop a tolerance, which is the need to increase the dose of the medication to achieve the desired effect. I am aware that I must inform Dr. Tarabein immediately should I ever experience any restlessness, tremor, rage or anxiety, or excessive sweating when I discontinue my pain medication. I do understand that for the duration of my care by Dr. Tarabein, I should not use any illegal drugs or alcohol, as controlled medicine may then pose serious harm to me, and I may be asked to undergo a drug screen at any time to monitor my treatments, should I be found in violation of this agreement, I may be dismissed from Dr. Tarabein's care. As I understand, I hereby release Easter Shore Neurology and Pain Center, Dr. Tarabein and his staff from all liabilties related to my controlled medicine use. I have read this agreement (which has been explained to me by Dr. Tarabein and his staff). I further agree to all terms and conditions herein, as well as the policies and procedures at Eastern Shore Neurology and Pain Center.
Signature: X (will sign in office)
Date:
Clinic Nurse: Eastern Shore Neurology & Pain Center R.M. Tarabein, M.D. www.easternshoreneurology.com
ESN Staff
Today's Date:
Date Established:
Patient's Name: Last name, First name, Middle name or initial-MR#
	Male Female
Address:
Phone #
City
State
Zip
SSN
DOB
	Single Married Widow Seperated Divorced
Occupation
Employment
Business Address
Business Phone #
Email Address:
Emergency contact name and Phone#
Referring Physician
Primary Care Physician
Guarantor's Info
1st Insurance Info
	The Ins. ploicy holder is the patient
Name(s) of other dependant(s) on the plan
2nd Insurance Info
	The Ins. policy holder is patient
Name(s) of other dependant(s) on the plan
Signature: X (will sign in office)
Patient's name Last name, First name, Middle name or initial-MR#
Date
General	Sweats Lack of energy Chills Weight loss Loss of appetite Feeling sick Fever None
Eyes	Vision deficit Halos around lights Double vision Blurring Eye pain Eyelid(s) twitching Eyelid(s) drooping Dry eyes Night vision loss Eye irritation Light sensitivity None
Ear/Nose/Throat	Ringing in the ears Earache Sore throat Ear discharge Nosebleeds Hoarseness Nasal congestion Dcreased hearing Sinus pain None
Cardiovascular	Fainting Fatigue Chest pain Palpitation Difficulty breathing when lying down Blackouts None
Respiratory	Snoring Cough Wheezing Shortness of breath Sleep disturbances due to breathing Congestion None
Gastrointestinal	Nausea Vomiting Indigestion Abdominal pain Dark or tarry stools Diarrhea Constipation None
Neuro	Headache Neck Pain Back pain Weakness Numbness Dizziness Tremor Siezure Loss of balance Muscle spasms/twitches Muscle aches None
Psych	Depression Anxiety Inattentiveness Phobia Panic attacks Detachment Tobacco Alcohol abuse Memory deficit Feeling hopeless Trouble sleeping None
Musculo-skeletal	Tenderness Back surgery Joint(s) swelling Neck Surgery Joint(s) pain None
Other Symptoms:(please describe)
	None
Signature X (will sign in office)
Patient's Name Last name, First name, Middle name or initial-MR#
Date
I, (signature) X (will sign in office)

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