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WELCOME LETTER

BUSINESS CARD

PATIENT SURVEY

PRACTICE INFORMATION COVER

MEDICAL INFORMATION

INSIDE

CUSTOMIZED PREMIUM

PRACTICE INFORMATION

INSIDE

APPOINTMENT CARD–SIDE 1

APPOINTMENT CARD–SIDE 2

BusinessCard

The ARSI Group

FINANCIAL POLICY

MEDICAL HISTORY

MEDICAL INFORMATION

COVER

PATIENT REGISTRATION

Jeffrey M. Braxton M.D.John A. Diw M.D. Jane B. Dow M.D.

Following graduation from medical school at Northwestern University in 1973, Dr. Dow spent 6 years at Cook County Hospital in Chicago doing research and completing a General Surgery Residency.

For the next 5 years, he taught at the Medical School in Yankton, South Dakota, and was in practice with Dr. Who, who was probably the world’s foremost expert in inguinal hernia repair.

Upon leaving the West, Dr. Dow entered private practice in Aurora in 1983 and now has 2 partners. Dr. Dow has pioneered, in this area, the use of microsurgery in the treatment of varicose vein problems.

He is a Fellow of the American College of Surgeons and a member of the American Society of Phlebology. Dr. Dow feels strongly that it is important a patient understand both the disease process and the options for treatment.

Dr. Dow graduated from the University of Illinois in Champaign, Urbana with a Bachelor’s of Science degree in Biology in 1980, where he was a member of the Alpha Phi Alpha Honor Society. Next, Dr. Dow attended the University of Illinois College of Medicine and received his M.D. Degree in 1984.

His 5 year General Surgery Residency was completed at the University of Illinois Metropolitan Group Hospitals in 1989. During training, he gained expertise in the full gamut of general, thoracic, trauma and vascular surgery. He became a Diplomate of the American Board of Surgery (Board Certified) in 1990.

Dr. Dow practiced surgery for 2 years in Laporte, Indiana prior to settling in the Fox Valley in 1991. He is on the Board of Directors of the Kane County Medical Society and was inducted as a Fellow of the American College of Surgeons (F.A.C.S.) in 1994. He serves on the board of Directors of Fox Valley Medicine and is a long standing member in the Warren Cole Surgical Society.

Dr. Dow graduated magna cum laude from Northern Michigan University in Marquette, Michigan with a Bachelor of Science in Biochemistry in 1985. He attended medical school at the University of Michigan in Ann Arbor, receiving his M.D. in 1989.

Dr. Dow then moved to Chicago for his surgical residency at Rush Presbyterian St. Lukes Medical Center. During this training, he developed a particular interest in the latest surgical techniques such as advanced laparoscopic surgery and the surgical treatment of cancer. After completing his training, he joined the practice in 1994.

Dr. Dow has maintained his interest in the academic aspect of surgery. He holds an active staff appointment at Rush Presbyterian St. Lukes Medical Center as an instructor and frequently gives lectures to medical students and residents in Surgery.

Dr. Dpw believes that caring and compassion are just as important as the latest techniques in the practice of the art of Surgery.

Doctors Dow, Dow & Dow

A Medical Practice

What are varicose veins and what are the symptoms associated with the disease?

Varicose veins are abnormally enlarged veins containing stagnant blood caused by the breakage or leaking of valves and/or dilatation or loss of elasticity of the wall of the vein. They may appear as bulging, bluish cords in the leg. On the other hand, spider veins are bluish red, thread-like veins which can occur in a cluster or may be isolated and may develop in the legs or the face. Most people with varicose veins complain of aching, swollen, heavy, and tired legs. They often complain of cramping which may be worse at night. Some patients complain of stasis dermatitis from the varicose veins which consist of itching or burning, possibly pigmentation, hardening, and darkening of the skin in the area of the varicose veins. This can lead to ulceration, an open sore, or breakdown of the skin caused by the intense pressure resulting from pooling of venous blood in the legs.

Who has varicose veins?

At least 70% of Americans suffer from varicose veins. Women are affected much more frequently than men at a ratio of 7 to 1. Causes include hereditary factors, female hormones, pregnancy, and trauma, with standing occupations and weight gain making the disease worse. People have a variety of symptoms from cellulitis and

ulceration formation to just a heaviness, swelling, and aching feeling in the legs. A patient who suffers from varicose veins may be simply considering the cosmetic defect that it presents. However, there may be an underlying disease process that needs aggressive treatment because progression of the disease will cause further problems in the future.

What are the deep and superficial venous systems and how do they affect circulation?

The legs have two veins systems: the deep system and the superficial system, which both serve, when they are healthy, to return flow of blood back to the heart. The arterial system is the system that brings blood to the legs and is not associated directly with varicose veins or venous disease although problems in both systems can occur at the same time. The deep venous system in the leg follows essentially the arterial system

which is a main femoral artery, a popliteal artery, and then smaller branches down to the lower leg and the foot. The superficial system is made up of the greater saphenous vein which feeds into the femoral vein at the groin and runs down the medial portion of the leg down to the foot. The lesser saphenous vein feeds into the deep popliteal vein behind the knee and runs down the back of

lesser saphenous and its branches, which include deep perforating branches to the muscles, are the veins that are involved in the superficial venous system varicose vein problems. Prior to the advent of the new lesser invasive procedures that are in use now by a select few surgeons who specialize in vein surgery, varicose veins would be removed by the stripping process. This will be discussed later.

How is a patient diagnosed and given a treatment plan for varicose veins?

The initial consultation of a patient coming in with problems for varicose veins includes a detailed medical history and physical examination, specifically including what kind of symptoms the varicose veins have, how long they have been present, what, if any, varicose vein treatment the patient has had in the past such as sclerotherapy or surgery, whether or not the vein problem has gotten worse or

Doctors Dow, Dow & Dow

All About

A Medical

Condition

Doctors Dow, Dow & DowJohn A. Dow, M.D. 123 First StreetSuite AAnywhere, IL 60001(555) 123-4567Fax: (555) 123-4568

Doctors Dow, Dow & Dow

EMERGENCY NUMBERSHotling (555) 987-6543

Hotling (555) 987-6543

Hotling (555) 987-6543

Hotling (555) 987-6543

123 First Street, Suite AAnywhere, IL 60001

(555) 123-4567 • Fax: (555) 123-4568

Drs. Dow, Dow & Dow

123 First Ave., Suite A • Enywhere, Illinois 60001

456 Second St., Suite B • Elsewhere, Illinois 60002

1234 Main Street, Suite A • Anywhere, Illinois 60000(123) 555-4567 • Fax (123) 555-4568

5678 1st Ave., Suite B • Elsewhere, Illinois 60001 (987) 555-6543

Drs. Dow, Dow & DowA Medical Practice

John A. Dow, M.D. Jane B. Dow, M.D.John C. Dow, M.D.

Welcome Letter

Dear Patient:

Welcome to Drs. Dow, Dow & Dow! We value your confidence in our ability to address your specialized healthcare needs.

Dr. Dow, Dr. Dow & Dr. Dow are Board Certified Surgeons, offering complete medical services. An expert group of support personnel complete the medical team caring for you.

The integration of experience and continuing education in a group practice setting distinguishes Drs. Dow, Dow and Dow in the field of surgery. You are assured of receiving the most up-to-date specialty care because of our on-going commitment to practicing quality medicine.

The physicians and staff members of Drs. Dow, Dow & Dow are dedicated to providing you with compassionate, comprehensive specialty care. Enclosed in this package is the information you need to create the necessary partnership between us. This package is designed to assist you in maximizing the benefits of the services you receive from us. This guide will acquaint you with our services so you will feel comfortable and confident here.

We look forward to being of service to you, and pledge to offer you the most advanced medical care available.

Thank you for choosing Drs. Dow, Dow & Dow.

Sincerely,

John A. Dow, M.D. Jane B. Dow, M.D. John C. Dow, M.D.

Drs. Brinkman, Spitz & BraxtonGeneral, Thoracic & Vascular Surgery

Dear Patient: Thank you for choosing Drs. Dow, Dow & Dow. This is to confirm your appointment with

Dr. at ❑ Anywhere ❑ Elsewhere on Directions to the practice are listed on the reverse side of this card, so please bring this with you on the day of your appointment.

Please bring to your appointment:

❑ Your X-Rays and/or Medical Records related to your current condition

❑ Signed Financial Policy

❑ Your Insurance card(s)

❑ Medicare Card

❑ A picture ID

❑ Completed Patient Information Form

❑ Referral Form From Primary Care Physician

❑ Co-Payment of $ . We accept cash, check or credit card.

❑ Fee for service of approximately $ . We accept cash, check or credit card.

❑ This card with your Questions for the Doctor (see reverse side).

❑

If you have any questions, please call me at (123) 555-4567

Sincerely,

Drs. Dow, Dow & DowA Medical Practice

Date

Patient Number

Your Medical SurveyWe need to know your past medical history to best understand how we can help you.

❏ Why are you here to see the doctor today?

PAST MEDICAL HISTORY- PATIENTPrior and Current Illnesses and Serious Injuries:

Prior Surgeries and Hospitalizations:

Current Medications - Dose and Schedule

Allergies and Reactions to Drugs, Foods or Other:

FAMILY MEDICAL HISTORYCheck all that apply:

❏ None ❏ Asthma

❏ CVA/Stroke ❏ Emphysema

❏ Hypertension

❏ Colon Cancer ❏ Chronic Obstructive ❏ Heart Disease

❏ Kidney Stones

Pulmonary Disease

❏ Congestive ❏ Diabetes

❏ Hypercholesterolemia ❏ Prostate Cancer

Heart Failure (elevated cholesterol)

Other Family History:

PLEASE FILL OUT BOTH SIDES OF THIS FORM Patient Name

1234 Main Street, Suite A • Anywhere, Illinois 60000(123) 555-4567 • Fax (123) 555-4568 5678 1st Ave., Suite B • Elsewhere, Illinois 60001 (987) 555-6543

Drs. Dow, Dow & DowA Medical Practice

Financial PolicyThank you for choosing us as your healthcare providers. We are committed to providing the very best care possible.

The following is a statement of our financial policy which we require that you read and sign prior to any treatment.

Your clear understanding of our Financial Policy is important to our professional relationship. Please ask our Financial

Counselor if you have any questions about our fees or Financial Policy.All patients must complete our “Patient Registration Form” prior to seeing the doctor.SELF PAY PATIENTS: Full payment is due at time of service unless a written financial arrangement has

been made. We accept cash, personal checks, VISA, and MasterCard.MEDICARE PATIENTS: We accept Medicare Assignment for your services, however, you are responsible

for the 20% unpaid by Medicare. Your 20% is due at time of service unless you have given us your secondary insurance information.

MEDICAID (IDPA) PATIENTS: All Medicaid Patients are responsible for bringing their eligibility card. Any Medicaid Patient who is determined by the State as having a spend down must pay

for service at time of service. Patient must have proof of IDPA coverage or pay in

full at time of service.INSURANCE PATIENTS: Full payment of your initial consult is required at time of service. Your insurance

will be filed for any medical services rendered. This make certain that any medical

expense will be applied toward your deductibles and/or processed by your insurance for payment of your claim. Patient is expected to pay at least 20% of total fee at time of subsequent service. Not all insurance plans pay the same benefits or apply the same deductible, thus there may be a balance due after your

insurance company has paid your claim. Since the insurance contract is an agreement between you and your insurance company, any unpaid balance will remain the responsibility of the patient. It is important for the patient to provide

the correct information for filing of any insurance claims. Please advise our front

desk if your insurance company has special requirements, such as precertification

or second opinions. We do all we can to help, but the ultimate responsibility for

fulfilling special policy requirements rests with the patient. MOTOR VEHICLE ACCIDENTS Full payment is due at the time of service. We do not bill your personal auto

liability insurance or any other involved party’s insurance. You are responsible for

all charges incurred for treatment to you regardless of any claim or legal action pending. We will provide you with a paid receipt you can turn in to your insurance

company.WORKERS' COMPENSATION We will file a claim with your employer or their insurance company if we have

verification that your injury is being considered as a Workers’ Compensation claim.

As treatment is being rendered to you, you are responsible for any amounts not covered under your Workers’ Compensation claim or paid in full by your employer

or his insurance carrier.CONTRACTED HMOs: You must have your referral from your primary doctor before you can be seen. Any

co-pay as indicated by your plan is due at time of service. Surgery cannot be scheduled

until we have a referral form or authorization number in our office.

Drs. Dow, Dow & DowA Medical Practice

Patient Medical HistoryName _______________________________________________________________________ Birth Date ______ / ______ / ______Height: _____ Feet _____ Inches Weight: ______ Lbs Recent Loss ______ Gain ______Do you smoke? Yes No If yes, packs per day ______ How many years? ______Do you drink alcohol? Yes No If yes, how much? __________________________ Beer Wine Other

Do you use drugs? Yes No If yes, what kind? _______________ When last used? _______________Do you have allergies to food and/or medication? Yes No If yes, please list:

Food or Medication __________________________ Reaction ______________________________

Food or Medication __________________________ Reaction ______________________________

Food or Medication __________________________ Reaction ______________________________

List all prescription and over the counter medications you are taking: Medication ______________________________ Dose ____________ # of Times/Day _______

Medication ______________________________ Dose ____________ # of Times/Day _______

Medication ______________________________ Dose ____________ # of Times/Day _______

Have you ever had surgery? Yes No If yes, please list: Type of Operation _________________________________________________ Date ____________

Type of Operation _________________________________________________ Date ____________

Type of Operation _________________________________________________ Date ____________

Have you had general anesthesia? Yes No If yes and you had any problems, please describe:

______________________________________________________________________________________

Have you had spinal anesthesia? Yes No If yes and you had any problems, please describe:

______________________________________________________________________________________If you are female, please answer the following: Date of last menstrual period ______ / ______ / _____

# of Pregnancies _____ # of Miscarriages _____ # of Abortions ______

# of Living Children _____ Health of children: Good Fair BadYour mother’s health: Good Fair Bad Deceased List her medical problems: ______________________________________________________________

If deceased, cause of mother’s death: ____________________________________________________

Your father’s health: Good Fair Bad Deceased List his medical problems: ______________________________________________________________

If deceased, cause of father’s death: _____________________________________________________

Do you now, or have you ever had, any of the following conditions? If yes, explain in space provided below: Yes No Aneurysms Yes No Hepatitis

Yes No Arthritis Yes No Hernia

Yes No Asthma Yes No High Blood Pressure

Yes No Bladder Problems Yes No HIV / Aids

Yes No Blood Clots Yes No Jaundice

Yes No Blood in Stool Yes No Kidney Disease

Yes No Breast Lump or Cyst Yes No Loss of Memory

Yes No Cancer (type?)__________________ Yes No Loss of Vision

Yes No Circulation Problems Yes No Prostate Trouble

Yes No Diabetes Yes No Rheumatic Disease

Yes No Dizziness Yes No Sores on Feet or Legs

Yes No Emphysema Yes No Stroke

Yes No Epilepsy Yes No Thyroid Disease

Yes No Head Injury Yes No Tuberculosis

Yes No Heart Disease Yes No Ulcer

Yes No Other, please explain________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Please be sure to inform us of any condition which may affect your care. Signing this form affirms that you have completed it to the best of your knowledge and no information has been withheld.Signature ______________________________________ Date _____ / _____ / _____ rev497

Patient RegistrationPlease print and complete all entries on both sides.

Adult Patient (Or Parent/Guardian of Dependent Named Below):

Acct. No. ______________________

/ /First Name MI Last Name Date of Birth

Sex: ❑ Male ❑ Female Marital Status: ❑ Single ❑ Married ❑ Divorced ❑ Widowed

Address City State Zip

( ) - ( ) - Daytime Phone Number Home Phone Number

May we leave medical information with family members, or on the telephone answering machine?

❑ Yes ❑ No

If no, do you have an alternate number we may reach you at, such as a cell phone or pager?

( ) -Mobile Phone/Pager

Social Security Number Driver’s License Number

Employer Occupation May we call you at work? ❑ Yes ❑ No

( ) - Employer’s Address Employer’s Phone

( ) - Whom may we thank for referring you to us? Referrer’s Phone Number

Minor Or Dependent Patient:

/ / First Name MI Last Name Date of Birth

Sex: ❑ Male ❑ Female Relationship to You ___________________________________Age____________________

Spouse:

/ /Spouse’s Name Date of Birth

Spouse’s Social Security Number Spouse’s Driver’s License Number

Spouse’s Employer Spouse’s Employer Phone

Dr Code________________________

For Office Use

Your Welcome Package. What is it?A professionally designed package of information which markets your practice and explainsto both the patient and the staff the practice’s expectations regarding accessing and payingfor services rendered.

Why is a Welcome Package important?

It markets your practice to:• Patients

• Networks

• Other Physicians

• Referring Physicians' Patients

• The Community you serve

It is a Foundation for Communication:• It Signifies Understanding

• It Reduces complaints and disputes

• It Constitutes Agreement

• It Makes patients partners in their treatment

Who is it for?

For the Patient• Provides certainty and knowledge of what to expect

• Enables them to make informed decisions

• Improves Customer Satisfaction

For the Practice• Establishes Professionalism

• Provides increased credibility

• Unites physician, patient and staff communications

• Makes your position easier and reduces upsets

• Delivers more money

• Improves Customer Satisfaction

You never get a second chance for a first impression. Whether you aremeeting a new patient for the first time ore greeting a patient who hasbeen with you since the practice opened, they should feel they havecome to the right practice for their healthcare needs. A PracticeWelcome Package, professionally designed and printed, allows thepatient to leave with tangible evidence of their visit, which is importantto patient satisfaction. Are your printed materials communicating theright message?

Quality improvement in this area necessarily starts with a re-evaluation of practice and patient expectations. The patient shouldfully understand that, being a member in good standing of the practice,they also have certain responsibilities. This includes being seriousabout following their treatment protocols as well as being responsible

for financial obligations. The practice has the responsibility to providecomplete and clear instructions of exactly what is expected of thepatient. The ARSI Group Practice Welcome Package satisfies thesegoals and more.

The purpose of our Welcome Package is to communicate a reality. Thisreality is that the patient is an integral part of the practice. The patientneeds to understand that the practice is their “partner” in healthcare,not their insurance carrier. This technique is extremely effective in ourcurrent environment, where patient satisfaction is measured by the“warm and fuzzy” feelings the patient remembers from interactionswith the staff and nurses. Providing our professionally designed material to your patients goes a long way to developing this partnership and improving patient loyalty to your group or physicians.

www.TheARSIGroup.com • 1-630-773-1395The ARSI Group

ProfessionalGraphicsCustomized forYour Practice

Give Patients a Professional Welcome!

Providing bundled solutions to today’shealthcare business office challenges.

Welcome Patients! New or Prospective...The Welcome Package is an invaluable tool in both the day to day operation and the marketing of your medical practice.

Why New Patients? Streamline your front and back office operations and impress new patients with a complete package,professionally designed, that includes all the information they need to know about your practice andtheir medical care. Inserted forms help you gather all the important data you need to know to keepyour office running smoothly, saving you time and money. Proper and complete gathering of patientinformation enables you to provide the best medical care possible.

Why Prospective Patients? Advertise your practice to the community through new homeowner welcome wagons, business expos,local mailings and more. Provide referring physicians with Welcome Packages to give to your prospec-tive patients. Enclose all the information you both need before their first visit in one convenient folder.This will make them feel more comfortable with your practice and reduce time consuming questions.

FamilyPractice

Heart Care Centers

1234 Anywhere Street, Naytown IL 60000

Pediatrics