2777 Mile High Stadium Circle Denver, CO 80211 Ph: 303-825-8822 Fax: 303-825-4022 www.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. Richard K. Heppe, M.D. Elias L. Hsu, M.D. Marklyn J. Jones, M.D. Lawrence L. Karsh, M.D., F.A.C.S. Daniel A. Kaufman, M.D. Donald J. May, M.D. Juan D. Montoya, M.D. Ferdinand J. Mueller, Jr., M.D. Alexander C. Philpott, M.D. Thomas J. Pugh, 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 W. Tillett, M.D. Stephen Bales, R.N., N.P Amanda Ferguson, R.N., N.P. Jennifer Gomez, 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 not contracted 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 possibility you 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 the building where we do our cystoscopies and surgeries, Physician Anesthesia Services which are the anesthesiologists in the surgery center, and outside hospital bills for any treatments we perform at these facilities. You may also receive a bill from LabCorp or Quest for labs we send out to be processed. If you have questions about the bills you may receive from these other 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 to our patients and we want to thank you for choosing TUCC to support you in your health care needs. To best meet your medical needs, you need to furnish the following item(s) upon arrival at our office:
Transcript
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. Richard K. Heppe, M.D.Elias L. Hsu, M.D.Marklyn J. Jones, M.D. Lawrence L. Karsh, M.D., F.A.C.S. Daniel A. Kaufman, M.D.Donald J. May, M.D.Juan D. Montoya, M.D. Ferdinand J. Mueller, Jr., M.D.
Alexander C. Philpott, M.D. Thomas J. Pugh, 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 W. Tillett, M.D.Stephen Bales, R.N., N.P Amanda Ferguson, R.N., N.P. Jennifer Gomez, PA-CShelly 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:
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
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 Mother _______ Father_______If parents’ are deceased, age and cause of death Mother__________________________ Father________________ __________________________SOCIAL HISTORY
Do 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][11/19/18][lp] Provider Initials: ___________
SKIN
Rash, Skin
Breakdown Lesions
EENT
2777 Mile High Stadium CircleDenver, 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
___ 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 2017 Colorado Health & Wellness Magazine
___ Advertisement on Internet search engine (Google, Bing, Yahoo, etc.)
___ Listing on online review site (Angie’s List, Yelp, etc.)
___ Digital advertisement promoting prostate cancer care at TUCC
(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]
THE UROLOGY CENTER
OF COLORADO
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Directions from specific Denver neighborhoods:
From the Wheat Ridge, Northwest Denver area Take 38th Avenue East to Federal Boulevard South Turn left on 20th Ave Turn left on Mile High Stadium Circle Drive one block east to TUCC on your left
From Lakewood Take US-6 East (6th Avenue) Go north on Federal Boulevard Turn right on 20th Avenue Turn left on Mile High Stadium Circle Drive one block east to TUCC on your left
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From Central Denver Take Colfax Avenue West Turn right on Federal Boulevard Turn right on 20th Avenue Turn left on Mile High Stadium Circle Drive one block east to TUCC on your left
2777 Mile High Stadium Circle
Denver, CO 80211
303.825. TUCC (8822)
303.825.4022 FAX I www.tucc.com
Directions to TUCC:
Going South on 1-25 Take Exit 211 (23rd/20th Avenue - Not 20th Street)
Go south on the Frontage Road
Turn right on 20th Avenue
Drive one block west to TUCC
on your right
Going North on 1-25 Take Exit 21 OA (West Colfax Avenue) and take a left on Colfax
Turn right (north) on Federal Boulevard
Turn right on 20th Avenue
Turn left on Mile High Stadium Circle
Drive one block east to TUCC on your left
TUCC is also conveniently located near several RTD and Light Rail stops.
RTD Stops: Federal Boulevard and 23rd Avenue Federal Boulevard and 17th Avenue
Light Rail Stops: C-Line at Mile High StadiumLocated just east of 1-25, northof Auraria Parkway
