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Texas Minimally Invasive Spine Surgery | Dr. Shaad Bidiwala

Best Dallas Spine Surgeon

  • Conditions
    • Do I Really Need Spine Surgery?
    • Cervical Disc Herniations
    • Lumbar Disc Herniations
    • Lumbar Instability
    • Lumbar Fractures
    • Lumbar Spinal Stenosis
  • Procedures
    • Nonsurgical Treatments
    • ACDF (Anterior Cervical Discectomy & Fusion)
    • Kyphoplasty
    • Lumbar Laminectomy
    • LMD (Lumbar Microdiscectomy)
    • Lumbar Interbody Fusion
      • ALIF (Anterior Lumbar Interbody Fusion)
      • PLIF (Posterior Lumbar Interbody Fusion)
      • TLIF (Transforaminal Lumbar Interbody Fusion)
      • XLIF (Extreme Lateral Interbody Fusion)
    • Minimally Invasive Instrumentation (Screws & Rods)
    • PLF (Posterolateral Lumbar Fusion)
  • Technologies
    • Technology for Cervical Disc Herniations
    • Technology for Compression Fractures
    • Technology for Lumbar Stenosis
    • Technology for Lumbar Instability
    • Technology for Lumbar Disc Herniations
  • Testimonials
  • News

Patient Forms

It is very important that we have as much medical information about you as possible before your visit.  In order to expedite your appointment, please fill out the forms below.

Thank you in advance for your help.  We look forward to seeing you soon!

PATIENT INTAKE FORMS

PATIENT INTAKE FORMS

Please complete the following forms for your upcoming appointment with Dr. Shaad Bidiwala. Once completed, please be sure to hit the “submit” button on the bottom of the page. If there are any questions please feel free to call our office staff at 214-823-2052 opt 4.

PATIENT INFORMATION

GENDER *
MARITAL STATUS *
RACE *
LANGUAGE *
HOW DID YOU HEAR ABOUT US? *

INSURANCE COVERAGE

PRIMARY CARD HOLDER *
SECONDARY COVERAGE *
SECONDARY CARD HOLDER

EMERGENCY CONTACT

PRIMARY EMERGENCY CONTACT *
PRIMARY EMERGENCY CONTACT
First Name
Last Name
AUTHORIZATION PERMISSION OF PHI *
SECONDARY EMERGENCY CONTACT
SECONDARY EMERGENCY CONTACT
First Name
Last Name
AUTHORIZATION PERMISSION OF PHI

CIRCLE OF CARE

PHARMACY

MEDICATION ALLERGIES

DRUG ALLERGIES? *

CURRENT MEDICATIONS

Add Remove

REVIEW OF SYSTEMS

DO YOU CURRENTLY HAVE ANY OF THESE SYMPTOMS *

PERSONAL HISTORY

PLEASE CHECK BOXES BELOW IF YOU HAVE BEEN DIAGNOSED WITH ANY OF THE FOLLOWING MEDICAL CONDITIONS *

FAMILY HISTORY

PLEASE MARK IF ANY IMMEDIATE FAMILY MEMBER HAS BEEN DIAGNOSED WITH ANY OF THE FOLLOWING MEDICAL CONDITIONS. *

SOCIAL HISTORY

DOMINATE HAND *
DO YOU HAVE A LIVING WILL? *
DO YOU HAVE A DNR? *
DO YOU HAVE ANY OBJECTIONS TO RECEIVING BLOOD OR BLOOD PRODUCTS? *
*IF OVER 65, HAVE YOU HAD PNEUMONIA VACCINE?
DO YOU TAKE ASPRIN? *
DO YOU HAVE A PACEMAKER? *
DO YOU TAKE A BETA BLOCKER? *
*IF OVER 65, HAVE YOU HAD ANY FALLS IN THE PAST YEAR?
HAVE YOU EVER SMOKED? *
ARE YOU A CURRENT SMOKER? *
WHAT TYPE DO YOU SMOKE?
HAVE YOU HAD AN ALCOHOLIC DRINK THE PAST YEAR? *
HOW OFTEN DID YOU DRINK THE PAST YEAR?
HOW MANY DRINKS IN A DAY?
HOW OFTEN DO YOU DRINK 6 OR MORE ON ONE OCCASION IN THE PAST YEAR?
DO YOU CURRENTLY USE ANY RECREATIONAL DRUGS? *

PRIOR SURGERIES/PRIOR HOSPITALIZATIONS

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REASON FOR VISIT

*

CONSERVATIVE THERAPIES

**YOUR INSURANCE COMPANY MAY REQUIRE CONSERVATIVE THERAPIES BEFORE APPROVING SURGERY. THE FOLLOWING INFORMATION WILL HELP WITH THE APPROVAL OF ANY TESTING TO BE ORDERED OR SURGERY IF INDICATED. **
HAVE YOU HAD TO USE A
HAVE YOU TRIED
DIAGNOSTIC IMAGING *
**WITHIN 6 MONTHS OF APPOINTMENT DATE**
*
MEDICATION THERAPIES *
***WITHIN THE LAST SIX MONTHS***
TRIGGER POINT INJECTIONS
EPIDURAL STEROID INJECTIONS
FACET JOINT INJECTIONS
WHERE DID YOU RECEIVE THE INJECTIONS?
BOTOX INJECTIONS
**HEADACHE/MIGRAINE PATIENTS ONLY**
HAVE YOU MISSED ANY WORK FOR THIS CONDITION? *

PHYSICIAN ONLY SECTION

I HAVE REVIEWED THE LISTED ROS/PFSH/SCREENING WITH THE PATIENT AND NOTED THE POSITIVE/NEGATIVE FINDINGS FOR THE VISIT.
Clear

TEXAS NEUROSURGERY ACKNOWLEDGEMENT FORM

AUTHORIZE:
Clear
  • I consent to receive the following documents electronically which are available through our website, unless I request a non-electronic paper copy of the documents disclosed herein.
  • Texas Neurosurgery’s Notice of HIPAA Privacy Practices
  • Texas Neurosurgery’s Financial Policy
  • Texas Neurosurgery’s Medication Policy/Agreement
  • Texas Neurosurgery’s Physician Assistant Information Guide
  • Texas Neurosurgery’s Disclosure of Physician Ownership
  • I authorize: The release of any medical and/or other information necessary to process my claim(s)
  • Payment of medical benefits to my treating physician or supplier for services rendered by Texas Neurosurgery
  • Consent for treatment by my treating physician with Texas Neurosurgery
  • I have read and understand/agree to abide by all the above policies and authorizations of Texas Neurosurgery.

DALLAS OFFICE

Mockingbird Station
6080 N Central Expressway
Suite #150
Dallas, TX 75206
United States

ADDISON OFFICE

Methodist Hospital for Surgery
17051 Dallas North Tollway
Suite 370
Addison, TX 75001
United States

DISCLAIMER

The content on this page is for informational purposes only, and is in no way intended to be medical advice. There is no substitute for a face-to-face evaluation by your physician or another qualified practitioner. As always, if you have an emergency, call 9-1-1, or go to the nearest emergency department.

Copyright © 2023 · Shaad Bidiwala MD PA | All Rights Reserved