Hackensack(University(Medical(Group( (Urology( 360(Essex(Street,(Suite(403(((Ι(((Hackensack,(NJ(07601(((Ι(((551F996F8090((((Ι((((

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1 IHORS.SAWCZUK,M.D.,F.A.C.S. Professor & Chairman Chief, Urologic Oncology John Theurer Cancer Center Executive VP & Chief Medical Officer RAVIMUNVER,M.D.,F.A.C.S. Associate Professor & Vice Chairman Chief, Minimally Invasive & Robotic Urologic Surgery Urologic Oncology & Kidney Stones KEVINR.BASRALIAN,M.D.,F.A.C.S. Attending MICHAELDEGEN,M.D. Clinical Assistant DEBRAFROMER,M.D. Assistant Professor Chief, Center for Bladder, Prostate & Pelvic Floor Health MICHELLEKIM,M.D. Assistant Professor Chief, Prostatic Disorders and Pelvic Tumors HARRYP.KOO,M.D.,F.A.A.P.,F.A.C.S. Professor Chief, Pediatric Urology DAVIDSHIN,M.D. Assistant Professor Chief, Center for Sexual Health & Fertility Men s Health RICHARDWATSON,M.D.,F.A.C.S. Professor Chief, Ambulatory Urology ALANN.LEIPSNER,MPH,MBA,FACHE Administrative Director Urology Academic Affairs Medical Library DearPatient, ThankyouforchoosingHackensackUniversityMedicalGroup Urology.Welookforwardto meetingyouandprovidingyouwiththehighestqualityurologicalcare.inadditiontoour physicians,nursesandclinicalassistants,whowilllookafteryourmedicalneeds;our administrativestaffisheretohelpyouwithscheduling,billing,andothernonfclinicalissues. Pleasetakeafewminutes,priortoyourfirstvisit,tocompleteandreviewthefollowing informationrelatedtoourpractice.doingso,willenableustoserveyouasefficientlyaspossible. Office&hours&by&appointment& To&schedule&an&appointment&please&call&551)&996<8090& & Includedinthispacketforyourreviewandcompletionarethefollowing: RegistrationForm NewPatientInformationForm Questionnaires) Directions&Map Inaddition,weaskthatyoubringthefollowingtoyourappointment: CompletedForms DriverslicenseorlegalformofpictureID InsuranceCard InsurancecoFpay Listofmedicationsandallergies Anyandallradiologyfilms&reports Pleaseprovideanyradiologyimagese.g.XFRay, MRI,CatScan,and/orUltrasound),orstudyresultsrelatingtoyourvisit Whileunderthecareofourphysiciansifyouneedtorenewaprescription,pleasecallyour pharmacyorfillouttheonlineprescriptionrenewalform,foundonourwebsite,urologynj.com. PleasenoteHackensackUMG UrologyhasanoFshowpolicy.Kindlycancelorrescheduleyour appointmentatleast24hoursinadvance.ifapatientisscheduledforanappointmentanddoes notcancelorreschedule,aletterwillbesenttothepatientchargingthem$25. Forbillingquestionscontactyourbillingrepresentativewithinthedepartmentat551F996F8626. ForallbillinginquiriesanddetailsonyourstatementpleasecontactHackensackUMG sbilling Officeat866)571F9238. OurgoalistoprovideyouwithexceptionalserviceandstateoftheartpatientFcenteredmedical careinanenvironmentthatissensitivetoyourneeds.pleaseletusknowhowwearedoingor howwemayimproveourserviceanddonothesitatetocallusifyouhaveanyquestions. ThankyouagainforchoosingHackensackUMG Urologyandwelookforwardtomeetingyou. HackensackUniversityMedicalGroup Urology 360EssexStreet,Suite403ΙHackensack,NJ07601Ι551F996F8090Ι

2 PatientInformation Date:& & SSN#:& & Last&Name:& & First&Name:& & Date&of&Birth:& & Gender:& &Male& &&&&&&&Female& Address:& & City:& & State:& & Zip:& & Special&Living&Arrangements: & &None&&&&&&& &Assisted&Living&&&&& &Nursing&Home& Home&Phone:& & Cell&Phone:& & EFmail&Address:& & Race:& American&Indian/Alaska&Native& Asian& African&American/Black& & Native&Hawaiian/Pacific&Islander& White/Caucasian& & Ethnicity:& Central/South&American& Cuban& Mexican& Puerto&Rican& & Other&Hispanic/Latino& NonFHispanic/Latino& Preferred&Language:& & Marital&Status: & Employment: &Employed&& &Medical&Disability& &SelfFEmployed&& &Retired&& &Unemployed& Employer:& &Employer&Address:& & Emergency&Contact:& &Relation:& Address:& &Phone&#& Pharmacy&Name:& &Phone&#& & How&did&you&hear&about&us:& & PrimaryPhysicianInformation NAME: & ADDRESS: & PHONE#: & & & &&&&&&&&&& & Patient s&signature& & & & & & Date&

3 InsuranceInformation PrimaryInsurance Name&of&Policy&Holder/Guarantor:& &DOB:& & Relationship&to&Patient:& &SSN#:& & Policy&Holder/Guarantor s&address:& & Status:&Employed&&&&Medical&Disability&&&&&&&&&&&SelfFEmployed&&&&&&&&&&&&&Retired&&&&&&&&&&&& Unemployed& Employer:& &Employer&Address:& & Insurance&Company:& & Insured s&policy/&id&#:& &Group&#:& & Insurance&Co.&Address:& &Phone&#:& & &&&&&&&&&&&&Name&of&Lab&Determined&by&Insurance:& & FFFFFFFFFFFFFF&DO&YOU&HAVE&ANY&ADDITIONAL&INSURANCE?&&&Yes&&&No&FFFFFFFFFFFFFF& SecondaryInsurance IF&YES,&PLEASE&COMPLETE&THE&FOLLOWING:& Name&of&Policy&Holder/Guarantor:& &DOB:& & Relationship&to&Patient:& &SSN#:& & Policy&Holder/Guarantor s&address:& & Status: &Employed&& &Medical&Disability& &SelfFEmployed&& &Retired&& &Unemployed& Employer:& &Employer&Address:& & Insurance&Company&Address:& & Insured s&policy/&id&#:& &Group&#:& & Insurance&Co.&Address:& &Phone&#:& & & PLEASE&PROVIDE&INSURANCE&CARDS&AND&PICTURE&ID&TO&FRONT&DESK& MAKE&CHECKS&PAYABLE&TO& HUMG &

360 Essex Street, Suite 403 Hackensack, NJ 07601 1-551-996-8090 Fax: 1-551-996-8221 Ihor Sawczuk, M.D. Debra Fromer, M.D. David Shin, M.D. Richard Watson, M.D. Michael Degen, M.D. Ravi Munver, M.D. Michelle Kim, M.

4 360 Essex Street, Suite 403 Hackensack, NJ Fax: Ihor Sawczuk, M.D. Debra Fromer, M.D. David Shin, M.D. Richard Watson, M.D. Michael Degen, M.D. Ravi Munver, M.D. Michelle Kim, M.D. Kevin Basralian, M.D. Harry Koo, M.D. Female Incontinence Questionnaire 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating, had a weak stream, or had to push or strain to urinate? 1 Less than half the time 2 About half the time 3 Almost always 2. Over the past month, how often have you found it difficult to postpone urination? 1 Less than half the time 2 About half the time 3 Almost always 3. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? 1 Once or twice per night 2 Three to four times per night 3 Five or more times per night 4. Over the past month, how many times during the day did you typically have to urinate? 0 Every 3 to 4 hours or less 1 Every 2 to 3 hours 2 Every 1 to 2 hours 3 Every half-hour or more

5 5. Over the past month, how often have you had urine leakage related to activity such as coughing, sneezing or exercise? 1 Less than once per week 2 At least once per week 3 At least once per day 6. Over the past month, how often have you leaked because of a strong urge to urinate? 1 Less than once per week 2 At least once per week 3 At least once per day 7. Over the past month, how often have you leaked without activity or urge? 1 Less than once per week 2 At least once per week 3 At least once per day 8. If you leak with activity, over the past month, at what level of activity did you experience leakage? 0 No leakage 1 Leakage only with strenuous exercise or activity 2 Leakage with moderate activity such as walking, coughing or lifting 3 Leakage with minimal activity 9. Over the past month, how often have you used pads for protection? 0 Never 1 Only on certain occasions 2 Daily for occasional accidents 3 Daily for frequent accidents or constant leakage 10. How much are you bothered by your symptoms? 0 Not at all 1 Slightly 2 Moderately 3 Greatly

9 Alfred Sanzari Medical Arts Building 360 Essex Street, Suite 403 Hackensack, NJ Directions from Paterson Area and West Follow Route 80 East, staying in local lanes to Exit 63B for Rochelle Park and Paramus. Exit ramp sign says Exit 63). Turn left off exit ramp and turn right at light onto Essex Street. Follow Hospital signs. At fifth light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the 4 th floor. From George Washington Bridge East Follow Route 80 West, staying in local lanes, to Exit 64B. Turn right at light onto Polifly Road. Travel north on Polifly Road. At second light, turn left onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor. From Southern New Jersey via the New Jersey Turnpike Follow Route 95-N.J. Turnpike North to the junction of Route 80. Take 80 West and stay in lanes for "Local Exits" to exit 64B for Hasbrouck Heights and Newark. Turn right at light onto Polifly Road. Travel north on Polifly Road. At second light, turn left onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor. From Northern New Jersey on Route 17 Follow Route 17 South to Essex Street exit. Turn left onto Essex Street. At fourth light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor. From Southern New Jersey on Route 17 Follow Route 17 North to Polifly Road turnoff. Go under the Route 80 overpass and turn left at the second light onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor. From the Lincoln Tunnel Take Route 3 West to Route 17 North to Essex Street exit. Turn right onto Essex Street. At second light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor. From the Garden State Parkway From the Garden State Parkway, either north or south, take Route 80 East. Follow directions above for Paterson Area and West. Revised 3/21/2013

10 Hackensack University Medical Center Campus Map HBF # Rev. 2/2012

Phone number: When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset:

Phone number: When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset: C H I R O P R A C T I C O R T H O P E D I C S A N D R E H A B I L I T A T I O N ILJXAi Pain Relief Clinics Please complete all sections. Full Name: Nickname: Gender: M F Age: Race: Date of Birth: I I Family