Complete Sleep Solutions | Lung Testing Form

39755 Date St., Ste. 101
Murrieta, CA 92563
Pulmonary Lab
951 698 6629
www.completesleepsolutions.com

1. READ AND FOLLOW PREPARATION INSTRUCTIONS FOR YOUR PULMONARY FUNCTION TEST.

Take any blood pressure medicines, insulin, antidepressants, cholesterol medicine and non-breathing related medicines if this is something you normally do.
If you take inhaled steroids (QVAR, Pulmicort, Flovent, Asmanex, Arnuity) you may continue to take them as usual.
If worsening shortness of breath makes you unable to stop the medications listed below for the recommended time frame, please take your medication and inform the pulmonary technician when you arrive for your test.

Stop these inhaled medicines for 24 hours before your appointment :

Anoro
Bevespi
Stiolto

Utibron
Trelegy
Incruse

Seebri
Spiriva
Tudorza

Stop these inhaled medicines for 12 hours before your appointment :

Arcapta
Brovana
Perforomist

Serevent
Striverdi
Advair

Breo
Dulera
Symbicort

Stop these inhaled medicines for 4-6 hours before your appointment:

Albuterol (ProAir,
Ventolin, Proventil)
Xopenex
(levalbuterol)

Atrovent
Combivent
Duoneb
Maxair

Primatene tablets
Albuterol tablets
Brethine tablets

Activities that should be avoided prior to testing:

Do not eat a heavy meal within 2 hours of testing (a few sips of water are fine).
Stop smoking at least 4 hours before the test.
No alcohol within 4 hours of the test.
No vigorous exercise within 30 minutes of the test.
Do not wear tight clothing that makes it difficult for you to take a deep breath.
No caffeine within 4 hours of testing.
No lipstick.

Please arrive 10 minutes before your appointment time and have all necessary paperwork completed.

Bring your photo ID and insurance card.

Please call if you have any questions regarding this test.

2. Please follow these instructions in preperation for your test

Registration

(Please Print)

Delmer W. Henninger M.D
39755 Date St Ste. 101
Murrieta, CA 92563

Tel : (951) 698-6629
Fax : (951) 698-8732

Date

Cell Phone

Home Phone

Patient (Last, First, MI)

Mailing Address

City

Zipcode

Sex
Male Female

Birth Date

Email Address

Medical Insurance
Yes No

ID#

Group#

SSN

Spouse's SSN (if used for billing)

Please list people we may discuss your Medical/Financial Record with, how they are related to you, and their contact information.

Insurance Assignment and Release

I certify that I have insurance coverage with

and assign directly to Dr. Henninger all insurance benefits, if ay, otherwise payable to me for and assign directly. I understand that I am financially responsible for all charges whether or not paid by insurance.

I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determaining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Medicare Authorization

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Henninger DBA complete Sleep Solutions for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of Medical or other information about me to release to the Centers for Medicare and Medicaid Services and their agents any information needed to determine these benefits or benefits for related services.

Print Name

Date

3. Acknowledgement of Receipt of Notice of Privacy Practices.

I hereby acknowledge that I understand and/or have received and/or been offered a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment. (Signing below means we will not release your medical records to anyone without your written consent)

Date

Print Name

If not signed, please indicate relation

2. PFT Questionaire

Full Name

Date

Referring Physician

Sex
M F

Date of Birth

Height

Weight

Preferred Language:

Reason for Testing:
Shortness of Breath Cough Asthma COPD Fibrosis Exposure Other

Is this pre-op?
No Yes

Previous pulmonary test?
No Yes

Smoking History
Never Ex Smoker Current Smoker

Packs/Day

for years?

and quit in

Packs/Day

for years

Other Meds that can effect lung function;

Diuretic

Beta-blocker

Amiodarone

Methotrexate

Bleomycin

PRIOR TO THIS SCHEDULED PFT TESTING, HAVE YOU

Used a short acting or "rescue" inhaler within the last 6 hrs?	No Yes
Used a long acting "maintainence" inhaler within the last 24 hrs?	No Yes
Used bronchodilators pills within the last 8 days?	No Yes
Smoked within last 6 hrs?	No Yes
Had any caffeine containing food/drink within last 6 hrs?	No Yes

Registration
(Please Print)

Talha Memon M.D
39755 Date St Ste. 101
Murrieta, CA 92563

Tel : (951) 698 - 6629
Fax : (951) 698 - 8732

Patient (Last, First, MI) :

Date :

Cell Phone :

Home Phone :

Mailing Address :

City :

ZIP :

Sex :

Male

Female

Birthdate :

Email Address :

Medical Insurance :

ID# :

Group# :

SSN :

Spouse's SSN (if used for billing) :

Secondary Medical Insurance :

ID# :

Group# :

Please list people we may discuss your Medical/Financial Record with, how they are related to you, and their Contact Information.

Insurance Assignment and Release

I Certify that I have insurance coverage with

and assign directly to Dr. Talha Memon all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.

I authorize the use of my signature on all insurance submissions. the above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Medicare Authorization I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Talha DBA Complete Sleep Solutions for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and their agents any information needed to determine these benefits or benefits for related services.

Signature :

Print Name :

Date :

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I understand and/or have received and/or been offered a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that i will be offered a copy of any amended Notice of Privacy Practices at each appointment. (Signing below means we will not release your medical records to anyone without your written consent)

Signature :

Date :

Print Name :

If not signed by patient, please indicate relation :

Insurance Card Front :

Insurance Card Back :

Driving Licence :

By electronically signing the Agreement, Patient consents to submitting this form in electronic form. Patient acknowledges that his/her electronic signature will have the same legal force and effect as a handwritten signature. Patient’s electronic signature, including date and time of signing will be stored electronically for Complete Sleep Solutions records.

THANK YOU

5. Directions to Murrieta Location :

From the South : Take 1-15 North, Exit WINCHESTER ROAD and turn RIGHT. Follow approximately 2 miles to MARGARITA ROAD and turn LEFT. Go to DATE STREET (which is the 4^th stop light) and turn RIGHT. We are in the 2-story medical building on the immediate left side of Date St. Enter the building through the sliding glass doors on the opposite side of building from Date St, and we are directly off the lobby in Suite 101.

From the North : Take 1-15 or 1-215 South, Exit MURRIETA HOT SPRINGS ROAD and turn LEFT. Follow approximately 2 miles to MARGARITA ROAD and turn RIGHT. Go to DATE STREET (which is the 4^th stop light) and turn LEFT. We are in the 2-story medical building on the immediate left side of Date St. Enter the building through the sliding class doors on the opposite side of building from Date St, and we are directly off the lobby in Suite 101.

** Please Note :

It is best to follow the above directions - many GPS and mapping programs give incorrect directions and location of our office.
The address is posted on the building, is covered by Palm Trees and may be difficult to see. We are the only 2-story building in the area.

Lung Testing Questionnaire Form

1. READ AND FOLLOW PREPARATION INSTRUCTIONS FOR YOUR PULMONARY FUNCTION TEST.

Stop these inhaled medicines for 24 hours before your appointment :

Stop these inhaled medicines for 12 hours before your appointment :

Stop these inhaled medicines for 4-6 hours before your appointment:

Activities that should be avoided prior to testing:

Please arrive 10 minutes before your appointment time and have all necessary paperwork completed.

Bring your photo ID and insurance card.

Please call if you have any questions regarding this test.

2. Please follow these instructions in preperation for your test

3. Acknowledgement of Receipt of Notice of Privacy Practices.

2. PFT Questionaire

PRIOR TO THIS SCHEDULED PFT TESTING, HAVE YOU

3. Your Cardio-Pulmonary & Sleep History

(Check all that apply)

4. Family History

Acknowledgement of Receipt of Notice of Privacy Practices

THANK YOU

5. Directions to Murrieta Location :

We see patients of all ages, including children as young as age 2.

Lung Testing Questionnaire Form

1. READ AND FOLLOW PREPARATION INSTRUCTIONS FOR YOUR PULMONARY FUNCTION TEST.

Stop these inhaled medicines for 24 hours before your appointment :

Stop these inhaled medicines for 12 hours before your appointment :

Stop these inhaled medicines for 4-6 hours before your appointment:

Activities that should be avoided prior to testing:

Please arrive 10 minutes before your appointment time and have all necessary paperwork completed. Bring your photo ID and insurance card. Please call if you have any questions regarding this test.

2. Please follow these instructions in preperation for your test

3. Acknowledgement of Receipt of Notice of Privacy Practices.

2. PFT Questionaire

PRIOR TO THIS SCHEDULED PFT TESTING, HAVE YOU

3. Your Cardio-Pulmonary & Sleep History

(Check all that apply)

4. Family History

Acknowledgement of Receipt of Notice of Privacy Practices

THANK YOU

5. Directions to Murrieta Location :

Please arrive 10 minutes before your appointment time and have all necessary paperwork completed.

Bring your photo ID and insurance card.

Please call if you have any questions regarding this test.