ROBERT M. PEROVICH, M_D., P.A. 2855 N. UNIVERSITY DRIVE CORAL SPRINGS, FL. 33065 PATIENT INFORMATION PLEASE PRINT CLEARLY Today's date:_ 7. « OF. 2022 Referred to this office by: Sho (lo pe Lebou) Phone: (AH) 7404433 Last Name: Bragec First: Sharan Middle: sweet Address: UAL Palera Road city: Parklarad sue: E[ Zi: 32010 Mobile Phone: AS4)_ IAI. G19 le Home Phone: (454) PAT, 042.1 Age: ‘ot Date of Birth: O72, 10.1491 Sex: MCE) Marital Status: $ @D Sep W D SS#: |g - S2__- MOle2_ Occupation: Retired Employer: ola Bus. Phone: ( nla Ext.__9l2 Primary Care Physician:_(4 bel G ak Phone = 35 4:940.0S530 Emergency contact person: Cenny Prager Relationship: 2 Bei ve a sy p:_ Sou Phone: (205) 45@. 1782 Ext. Primary Insurance Co: ThawanaChoice PPO Secondary Insurance Co: _ Pharmacy Name, Address, Phone#:_ CVS Thareiacy Taal lestvield penngs Br ADOeT Do you have an advance healthcare ireative (living wil) or heatincare surrogate decision maker?es) No Previous psychiatrists (Name, City, Month/Year, Duration): De Leonard Lebrow , Sunrise TL Cereasod 02.2022) years Previous psychotherapists (Name, City, Month/Year, Duration): ola Previous psychiatric hospitalizations (Name, City, Month/Year, Duration) nf2 Patient Info Sheet 5/2018Robert M. Perovich, M.D. P.A Please briefly describe the main problem that spout yp you here: assed ua! —Need_new psych frist Tene re re Please list ll medieal problems (asthma, Depressed betes, hypertension, major surgeries, ec) None Women: Ae you Pregnant? Yes GY Nose Use bith onl Aenean) List all current medications and dosages (including over-the-counter drugs, herbal treatments): Sas_atiached Ti List all family members (parents, siblings) who have ever suffered from mental illness (in clude type of illness or diagnosis): > e : y (stoned Bek Circle all ric med Antidepressants: a uoxetng ‘Garttine), Pail (paroxetine), Lavox (Tuvoxamine), Celexa (citalopram) CexaprO5Wellbutrn (bupropion), Remeron (mirtazapine) venlafaxine), Cymbalta (duloxetine), Pristig, Vibryd, Tofranil (imipramine), Elaih (amitriptyline), Pamelor (nortriptyline), Norpramin (desipramine), Sinequan (doxepin), Nardil (phenelzine), Pamate, MAO-1, Serzone, ‘Symbyax, Anafranil cee Viibryd, Fetzima, Trintellix Antipsychoties: Risperdal, Zyprexa, Seroquel, Geodon, Abilify, Invega, Fanapt, Saphris, Latuda, Vraylar, Rexulti, Haldol, Prolixin, Thorazine, ‘Navane, Stelazine, Clozapine, Moban, Loxitane, Mellaril, Trlafon ADHD: Adderall, Concerta, Vyvanse, Focalin, Metadate, Ritalin, Dexedrine, Strattera, Cylert Sleeping Pills: Ambien (zolpidem), Lunesta (eszopiclone), Sonata (zaleplon){Restor (uurazepam), Prosom (estazolam), Rozerem, Trazodone (temazepam) Halcion (triazolam), Dalmane Memory: Aricept, Exelon, Exelon patch, Razadyne, Namenda Miscellaneous: Provigil (modafinil), Nuvigil, Antabuse, Cogentin (benztropine), Artane, Subutex, Suboxone Others medications not list Mhasen rasp Patient Signatur Patient Info. Sheet 2018 02.0%.2022,ROBERT M. PEROVICH M.D., P.A. 2855 N. University Drive Suite 500 Coral Springs, FL 33065 954-346-9404 AUTHORIZATION TO USE CREDIT CARD |, the undersigned, authorize Robert M. Perovich M.D., to charge my credit card for all appointments in which I do not provide an alternative payment or in the event that I (or the party for whom | am financially responsible) fail to attend a scheduled appointment, or do not notify my provider at least 24 business hours advance notice for a cancelled appointment, as agreed to in the “Consent for Evaluation & Treatment / Practice Policies’ document. Furthermore, for outstanding payments of services rendered, 1 authorize charges to my credit card for the full amount due. I agree not to dispute charges for any of these reasons and understand that clinical information may need to be released if dispute is initiated. I further authorize Robert M. Perovich M.D.. to disclose information about my attendance and/or cancellation to my eredit card company if I dispute a charge. This form will be securely stored in a clinical file and may be updated upon request at any time. PRIMARY CREDIT CARD INFORMATION (may be HSA): Type: OVisa MasterCard wAMEX Discover Credit Card Number: 3 1A 1146519 207 Expiration Date: _10[24 Verification/Security Code:_ 332.0. Full Name (as printed on card): Billing Address: Signature: Date: 09,20 SECONDARY CREDIT CARD INFORMATION: Type: OVisa OMasterCard OAMEX ODiscover Credit Card Number: 7 Expiration Date: ____Verification/Security Code: Full Name (as printed on card): Billing Address: Signature: Date: +*Your credit card will be charged if any of the following conditions apply: * Participation in treatment {including phone or telemedicine sessions) without payment rendered + Other services provided such as writing letters/reports, legal proceedings, collateral care, etc. * Extensive phone calls that require clinical decisions & support lasting more than a few minutes * Cancellation less than 24 business hours in advance + No-show for a scheduled appotnimentROBERT M. PEROVICH, M.D., P.A. RESPONSIBIILITY STATEMENT FEES AND INSTRUCTIONS: ‘The fee for professional services are due at the time of visit unless prior arrangements have been made. If you are using insurance, it is your responsibility to pay deductibles, coinsurance, and any balances not paid by your insurance. Billing your insurance is a courtesy. As such, you are responsible for the entire bill until your insurance pays. If your financial responsibility has not been met within one month after the date of service, you will be responsible for the entire balance plus 1.5% monthly service charge. If your account becomes past due, we will take all iecessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all the collection fees that are incurred, In case of suit, you agree the venue shall be in Broward County. There will be a $25.00 fee on returned checks. Attention Medicare Patients: Dr. Perovich accepts Medicare assignment. Accepting assignment means that we have agreed to lower our offfice fee to what Medicare allows us to charge. Medicare pays 80% of all visits. If you have a supplemental insurance, it may pay all or a portion of the coinsurance not paid by your supplemental insurance. CANCELLATIONS: If an appointment is missed or canceled within 24 hours of the scheduled appointment time, you will be responsible for the full charge of that appointment. It is the discretion of the office whether or not to give special consideration for unexpected circumstances regarding a missed appointment. 1 authorize the release of any/all medical information to my insurance carrier that is pertinent and necessary to process claims for payment on my behalf. I agree to be financially responsible for all charges. I have read this information and understand it. I have read the HIIPPA Notice of Privacy Practices posted in the waiting room. Patient's Name (Print): ___Date: 02,089,202. Signature: Social Security #: (Te G2 SO(o2 (Qf minbr, parent/iégal gdardian signature) (Optional) L authorize the release of all medical information to the referring physician or therapist. Name of referring physician or therapist: Srelley of De. Lebow’s Rice Patient Signature: (ly, ‘(If minor, parent/legal guardian signature) Respor‘Sharon Brager’s Meds as of February 2022 NAME SIZE ADVAIR 250/50 \VENTOLIN METOPROLOL 50mg LISINOPRIL 40 mg, AMLODIPINE BESYLATE 2.5 mg CRESTOR (rosuvastatin) 40mg. DOSAGE, Twice each day On demand % (25mg) twice each day Once each day Once each day 4 (20mg) every other day POST WHIPPLE PROCEDURE REQUIRED MEDS: PANTOPRAZOLE SOD 40mg CREON 36000 lipase REGLAN (metoclopramide) 5 mg SYNTHROID 50 meg VITAMIN D3 2000 mg COLASE SOFTENER 200mg TRULANCE (plecanatide) 6 me. XANAX (Alprazolam) mg LIBRIUM (Chlordiazepoxide)5mg RESTORIL (Temazepam) 30 mg EFFEXOR (Venlafaxine) 150 mg EFFEXOR (Venlafaxine) 37.5mg PROLIA Injection INTERNIST Dr. Michael Funk Multimed Florida 3001 Coral Hills Drive Suite 170 Coral Springs, FL 33065 954.840.0530 mfunk@muttimedfi.com Psychiatrist Dr. Leonard Lebow (deceased 02.2022) 954.748.4433, Gastroenterologist Dr. Ronen Arai 954.726.2428 Rheumatologist Dr. Mathew Farbman 944.344.2288 Once each day 2with meals 3 times each day Once each morning ‘Once each day ‘Once each day ‘Once each morning each day each day Lat bedtime 2each morning ‘Leach morning every 6 months PURPOSE Asthma Asthma Blood pressure Blood pressure Blood pressure Cholesterol Control Acid Control Digestive Enzymes Digestive Support Metabolism Support Osteoporosis Support Bowel Mover. Assistance Bowel Movem. Assistance Anti Anxiety Anti Anxiety Sleep Anti Depression Anti Depression Osteoporosis Pharmacies CVS Pharmacy 954.282.5001 Humana Pharmacy 800.379.0092 Humana Choice PPO 1D #H05835110 Cardiologist Dr. Michael Funk See internist, above