Patient Registration

May we contact you via email? *
May we send you text messages? *
Marital status *
IS YOUR VISIT DUE TO A WORK-RELATED INJURY, AN AUTOMOBILE ACCIDENT, OR A PERSONAL INJURY CLAIM? *

Patient Acknowledgment of Receipt of Notice of Privacy Practices

I, the undersigned, hereby acknowledge that I have reviewed and received a copy of this office's Notice of Privacy Practices explaining:
 
 1. How this office will use and disclose my protected health information.
 2. My privacy rights with regard to my protected health information.
 3. This office's obligations concerning the use and disclosure of my protected health information.
 
 
I understand that the Notice of Privacy Practices may be revised from time to time and that I an entitled to receive a copy of any new revised practices upon request. 
 
I also understand that if I have questions or complaints, I may contact:
 
Ricardo M. Buenaventura, MD
7244 Far Hills Ave.
Centerville, OH 45459
937-395-1300
 
You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures.  Please contact our office for information on how to contact the U.S Department of Health and Human Services.
 
To Review a copy of our Privacy Policy, click here:  https://www.painreliefofdayton.com/your-privacy
 
Patient or Personal Representative
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Signature: *
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A Letter to Our Patients Regarding Our Role in Your Care

Dear Patient,
 
We are happy to see you in our practice.  We utilize a wide array of therapies and non-addicting medications to minimize and control your pain.  Our goal is to do this without the use of narcotics or controlled pain medications.  In most cases, we prefer not to prescribe or escalate any controlled pain medicines you are currently taking.  
 
Several new procedures and non-controlled pain medicines have been developed in the last few years.  Our approach is to implement these therapies and medications into your treatment regimen.  We will evaluate your case and offer the most reasonable, safe, and beneficial treatment for you.  We may also use/recommend physical therapy.
 
We will make suggestions to your referring physician about what medicines, including controlled medicines, we think are right for you and your condition.  We may start you on some non-controlled pain medicines and then turn these over to your primary care doctor for the continuance of these.  Other times we may suggest all the medicines to him/her so that they may decide which are safe and best in your case.
 
Hopefully, through the use of these pain-relieving procedures and non-narcotic pain medications, we can minimize or delay the need for controlled substances.  This will delay the development of tolerance or dependence on these medicines later.  Please keep in contact with your primary care physician and make sure you have enough medicine to get back into their clinic.
 
From all of us at Pain Relief of Dayton, we look forward to seeing you and making your evaluation a pleasant one.
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Initial Consent for Treatment

I desire to be treated at Pain Relief of Dayton by Dr. Ricardo Buenaventura. I understand that I may discontinue treatment at any time.  I authorize for the examination, diagnosis, and general treatment which may include but not limited to clinical evaluation, medical history, physical examination, psychological examination.  The purpose of such evaluations is to assist in identifying the cause of my problem and applying the most appropriate medical treatments possible.  I understand and consent to the administration of an evaluation. After my evaluation, my doctor may offer treatment options which may include but are not limited to non-narcotic medications, physical therapy, injection therapy, chiropractic treatments, diagnostic imaging, or psychological therapy as considered necessary and advised by my physician.
 
I understand that treatments provided by Pain Relief of Dayton are voluntary and in no way guaranteed to relieve my pain fully or completely.
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Office Policies

MISSED APPOINTMENT POLICY
Not Keeping scheduled appointments hinders our ability to provide quality care.  We require a 24-hour notice for all cancellations.  This allows us to offer your time slot to another patient.  A failure to provide cancellation notice will result in a $25.00 fee to your account.  This is not payable by your insurance and will be your responsibility.
 
CO-PAYMENTS AND DEDUCTIBLES
All co-payments, co-insurance, and unmet deductible amounts will be due at the time of service.  Our office will make every effort to notify you of any deductible amounts due but ultimately you are responsible for knowing this information.
 
FINANCIAL AGREEMENT
I understand that the bill is my responsibility.  I assign payments to be made directly to Pain Relief of Dayton of all insurance benefits and agree to pay any balance due.  I understand I will be responsible for any additional fees incurred from the following: Returned Checks, Missed Appointments, Copies of Medical Records.
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Confidential Communication

As required by the Health Information Portability and Accountability Act of 1996 (HIPAA), you have the right to request that communications concerning your personal health information be made through confidential channels.
 
I request the use of the following confidential channels for the communication of information related to my personal health, treatment, testing results, or appointment reminders:
May we leave a detailed message at this primary number? *
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Opioid Risk Tool

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Are you: *
Do you have a Family History of Substance Abuse? *
Do you have a Personal History of Substance Abuse? *
Are you between the ages of 16-45? *
Do you have a history of Preadolescent Sexual Abuse? *
Do you have any of the following psychological disorders: Attention Deficit Disorder, OCD, Bipolar, Schizophrenia *
Have you been diagnosed with depression? *
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FOR OFFICE USE ONLY

TOTAL __________________

Total Score Risk Category
Low Risk 0-3
Moderate Risk 4-7
High Risk 8+

Personal and Family Medical History

Mark the medical conditions that apply to you or any immediate family
 PersonalSiblingMotherFather
Seasonal Allergies
Anemia
Anxiety
Arthritis
Asthma
Cancer
Cataracts
Thyroid Disease
CHF
Clotting Disorder
COPD
Depression
Diabetes
GERD
Heart Murmur
HIV/AIDS
Hyperthyroidism
Hypothyroidism
Kidney Disease
Heart Problems
MI
Nerve Trouble
Osteoporosis
Seizures
Stroke
Substance Abuse
High Blood Pressure
Tuberculosis
Ulcers
High Cholesterol
Gout
Glaucoma
Hepatitis C

Personal Surgical History

Have you had any of the following surgeries? *

Social History

Product use
 NoneOccasionallyWeeklyDaily
Alcohol
Tobacco
Recreational drugs
Caffeine
Exercise Daily

Review of Systems

Check any that may apply to you: *

Tell Us About Yout Current Pain Condition

Chronicity: *
Onset: *
Frequency: *
Progression Since Onset: *
Pain Quality:
Pain Radiates to: *
Pain Score. from 0-10 with 0 being no pain, and 10 being the worst pain, how would you rate your pain on average: *
Pain Severity: *
Pain is aggravated by:
Pain is:
Stiffness is Present:
Do you have any of the following associated with this condition: *
Do you have any of the following risk factors: *
Have you tried any of the following treatments for your pain: *
How long have you tried those treatments: *
How much relief did you receive from those treatments:
Does the pain affect your sleep:
My pain impacts/affects my life in the following ways, select all that apply:
Do any of the following apply to you: *
Do any of the following things improve your pain:

Current Medication

List any current medications you are taking. If you have your own list, you may bring that to your appointment instead.
 NameDoseHow long have you been taking?
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2
3
4
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Do you have any drug allergies? *
Do you take a blood thinner medication: *

Completion

I certify that the information I have provided above is accurate to the best of my knowledge.
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