J. KEVINKAUFMAN,M.D.,F.A.C.S.SurgicalConsultantsofAmerica809W.HarwoodRdSuite202Hurst,TX76054Phone:817.377.0143Fax:817.377.0173

PATIENT MEDICAL HISTORY All questions contained in this questionnaire are strictly confidential

and will become part of your medical record.

PATIENT INFORMATION

Name: M F DOB: AGE:

Marital status: Single Partnered Married Separated Divorced Widowed

Patient Address: City State Zip

Home Phone: Cell Phone:

SS#: Occupation

Employer: Employer Phone #:

Employer Address: City State Zip

What type of work do you do (or did do if retired)?

How long have you been at your present job?

Spouse / Next of Kin: Phone #:

Emergency Contact: Phone #:

Family Physician / Internist: Phone #:

Referring Physician: Phone #:

Pharmacy Name: Phone #:

INSURANCE INFORMATION

PRIMARY INSURANCE: Member/Subscriber ID:

Address:

Primary Subscriber: Group Number:

Relationship to Policy Holder: Self Spouse Child

SECONDARY INSURANCE: Member/Subscriber ID:

Address:

Primary Subscriber: Group Number:

Relationship to Policy Holder: Self Spouse Child

CHIEF COMPLAINT/REASON FOR TODAY'S VISIT:

Were you injured in an accident: YES NO Motor Vehicle Accident Worker's Comp Accident Slip& Fall Other

Reason for Today's Visit (What are your symptoms and when did they start?)

On a scale of 1 to 10 - One (1) being slight pain and ten (10) being severe pain, what would you rate your pain today?

Do you have and of the following and where: (Circle which): Numbness Tingling Burning Location:

Do you have any weakness and location: Yes No Location:

Do you have any of the following: (Circle which): Vision problems, Hearing problems, Fainting, Dizziness, Nausea, Vomiting, Loss of Balance, LOC, Stroke, TIA or Seizures.

What makes your symptoms worse?

NAME: _______________________________ DOB:________________ DATE: ______________

What makes your symptoms better?

How far are you able to walk?

CURRENT SYMPTOMS / TREATMENT:

Have you had any of the following treatments for your CURRENT symptoms: HAVE YOU HAD ANY OF THE FOLLOWING TESTS FOR YOU’RE YOUR PROBLEMS

TREATMENT YES NO RELIEF - NONE, SOME, GOOD YES NO

BED REST CT SCAN

ACUPUNCTURE MYELOGRAM

AQUATHERAPY MRI

PHYSICAL THERAPY X-RAYS

EXERCISE THERAPY DISCOGRAM

THERAPEUTIC MASSAGE EMG / NCV

TRACTION BONE SCAN

ELECTRO-STIMULATION OTHER

TENS UNIT

SOFT COLLAR

LUMBAR CORSET OR BRACE

APPLICATION OF HEAT/ICE Are you claustrophobic?

MEDICATIONS

CHIROPRACTIC MANIPULATION

EPIDURAL STEROID INJECTION

TRIGGER POINT INJECTIONS

OTHER

PAST MEDICAL HISTORY:

Please list illnesses (Example: High blood pressure, diabetes, cancer, heart, lung, liver or kidney problems.

Do you have any METAL in your body? (Pacemaker, aneurysm clips, rods, screws, shrapnel, etc) YES NO

Have you ever been treated for any of the following: YES NO YES NO

Alcohol or Drug Abuse Heart Attack

Anemia Heart Disease / Angina

Asthma High Blood Pressure

Bleeding Disorder HIV / AIDS

Cancer Kidney Problems

Diabetes Liver Problems

Emphysema Stroke

Epilepsy Ulcer

PAST SURGICAL HISTORY: Please list all operations you have had:

Type of Surgery Month/Year Surgeon City/State

NAME: _______________________________ DOB:________________ DATE: ______________

ALLERGIES: Please list all allergies to medications:

Medication Name: Reaction

MEDICATIONS: Please list all allergies to medications:

Please check if you are taking any of the following: Echinacea Garlic Ginger Ginko Biloba Ginseng St. John's Wort Metabolife Kava Kava Feverfew Ephedra

Prescription Medication Name: Dose and Frequency

FAMILY HISTORY: Please list any serious illnesses that have occurred in your family.

Relative Living Deceased Health problems or Cause of Death

Mother

Father

Sibling - Brother / Sister

Sibling - Brother / Sister

Sibling - Brother / Sister

Child - Male / Female

Child - Male / Female

Child - Male / Female

SOCIAL HISTORY:

Marital Status: Circle one: Single Married Divorced Widowed

Spouses Name: Phone #:

Tobacco use: How much? How often? How long?

Alcohol use: How much? How often? How long?

Caffeine use: How much? How often?

Drug use: Yes? No?

OTHER:

Is there a family member or friend living with or near you who will be available to assist you once you have been discharged from the hospital should the need arise?

Name: Phone #:

Name: Phone #:

J. KEVINKAUFMAN,M.D.,F.A.C.S.SurgicalConsultantsofAmerica809W.HarwoodRdSuite202Hurst,TX76054Phone:817.377.0143Fax:817.377.0173

REVIEW OF SYSTEMS NAME: _______________________________________________________________ DOB: ______________________________________________

Do you currently have or have you had past problems with:

CONSTITUTIONAL

Excess Fatigue YES NO Fever YES NO

Night Sweats YES NO Weight Loss YES NO

EYES:

Cataracts YES NO Glaucoma YES NO

Infections YES NO Wear Corrective Lenses YES NO

Injuries YES NO Explain:

Date of Last Exam:

EAR, NOSE, THROAT & MOUTH:

Balance Disturbance YES NO Ear Infections YES NO

Hearing Loss YES NO Ringing in Ears Right Left Both YES NO

Wearing Hearing Aids Last Exam: ___________ YES NO Inability to Smell YES NO

Nasal Congestion YES NO Nasal Drainage Color: ___________________ YES NO

Nose Bleeds YES NO Sinus Headaches YES NO

Sinus Problems YES NO Mouth Sores YES NO

Sore Throats YES NO Hoarseness YES NO

CARDIOVASCULAR:

Chest Pain or Angina YES NO Heart Murmur YES NO

High Blood Pressure YES NO High Cholesterol YES NO

Irregular Pulse YES NO Leg Pain While Walking YES NO

Swelling of Hands and/or Feet YES NO

RESPIRATORY:

Asthma YES NO Bloody Sputum (Saliva) YES NO

Bronchitis YES NO Chronic Cough YES NO

Emphysema YES NO Lung Cancer YES NO

Pneumonia YES NO Shortness of Breath YES NO

Date of Last Chest X-ray:

GASTROINTESTINAL:

Abdominal Pain YES NO Blood in Vomit YES NO

Change in Bowel Habits YES NO Colon Cancer YES NO

Indigestion or Pain with Eating YES NO Jaundice YES NO

Liver Disease YES NO Nausea YES NO

REVIEW OF SYSTEMS - CONTINUED GENITOURINARY:

Blood in Urine YES NO Difficulty Staring or Stopping Urine Stream YES NO

Endometriosis (Female) YES NO Incontinence YES NO

Kidney Stones YES NO Painful Urination YES NO

Prostate Cancer (Male) YES NO Urinary Tract Infections YES NO

Uterine or Cervical Cancer (Female) YES NO

MUSCULOSKELETAL:

Arm or Leg Numbness or Tingling YES NO Arm or Leg Pain YES NO

Arm or Leg Weakness YES NO Back Pain YES NO

Broken Bones YES NO Joint Pain or Swelling YES NO

List:

INTEGUMENTARY:

Breast Pain, Tenderness, Swelling (Female) YES NO Date Last Mammogram ( Females)

Nipple Discharge YES NO Skin Cancer YES NO

Skin Disease YES NO

NEUROLOGICAL:

Difficulty with Speech YES NO Difficulty with Coordination in Arms and/or Legs YES NO

Disorientation YES NO Double o Blurred Vision YES NO

Face Weakness YES NO Fainting Spells or "Blacking Out" YES NO

Headaches YES NO Problems with Memory YES NO

Seizures YES NO

Please place the appropriate letter in the areas of the body where you experience pain, burning, tingling and/or numbness on the drawings:

X - PAIN B - BURNING T - TINGLING W - WEAKNESS

NAME:____________________________________________________________ DOB: ________________________________________________

J. KEVIN KAUFMAN, M.D., F.A.C.S.Neurological & Complex Spine Surgery

Hurst/Lancaster/Farmers Branch

809 W. Harwood, Suite 202

Hurst, Texas 76054

817-377-0143 Phone

817-377-0173 Fax

CONTROLLED SUBSTANCE AGREEMENT

Between: J. Kevin Kaufman, M.D. and patient ____________ _

The purpose of the agreement is to prevent possible misunderstandings about certain medicines doctors at this

office may prescribe to you. The terms and the explanations in this agreement are non-negotiable and meant to

help the patient and the doctor to comply with all laws.

Narcotics are recognized and useful medications. They are only effective when used properly. However, narcotics

have a high abuse/misuse potential and can have severe side effects such as drowsiness, vomiting, constipation

and even death. Because of this, you are now entering into a binding agreement that will remain in effect as long

as you are receiving narcotics.

I hereby agree to the following terms and conditions:

1. I understand the managing and controlling the prescriptions is my sole responsibility. Lost or stolen

prescriptions will not be replaced without a police report and an appointment with the doctor. NO after

hours prescriptions will be issued.

2. I agree to use prescribed medications only as directed by the prescribing physician. I will NOT attempt to

self-medicate myself. Controlled substances are only ordered for three months.

3. I will use only one pharmacy. I will provide the name of this pharmacy to the doctor upon request and/or

present the prescription bottle for examination.

4. I agree to undergo urine drug testing when requested by the physician. I understand the purpose of the

urine drug test is to monitor all substances that I am using. I understand that failure to undergo such

testing can result in immediate termination of all prescriptions medications discharge from the doctor's

care. I also understand that non-compliance may give my insurance carrier the right to disallow further

medical treatment.

5. Under no circumstances will I use additional drugs, whether legal or illegal, while using the medications

prescribed by my doctor. I will not accept or request any controlled substances from any other physicians

or individuals while I am receiving medications from the physician indicated below. I understand that it is

illegal to do so and may endanger my health.

I acknowledge that I discussed or had an opportunity to discuss this agreement with my doctor. I have read this

agreement and fully understand its terms and have signed it freely and voluntarily without any inducement or

pressure. I intend my signature to be a complete and unconditional acceptance of the terms and conditions of this

agreement.

Patient: Date: ---------------- --------------

J. KEVIN KAUFMAN, M.D., F.A.C.S.Neurological & Complex Spine Surgery Hurst/Lancaster/Farmers Branch 809 W. Harwood, Suite 202 Hurst, Texas 76054 P: 817-377-0143 F: 817-377-0173

FINANCIAL POLICY

Thank you for choosing us as your health care provider. We are committed to the excellent treatment

of all our patients and we will always do our best to provide exceptional care-whether in the office or

at the hospital. As in most medical practices, medical fee reimbursements continue to decrease while

our costs continue to increase. We have implemented the Patient Financial Policy to help control costs

so that we can always provide high quality medical care.

SELF PAY

Payment is required at the time of service for office visits. The staff can let you know the cost of your

visit prior to your appointment if needed.

HMO, PPO, MEDICARE

or WORKERS COMPENSATION

If you are covered by an HMO, PPO, Medicare or WORKERS COMPENSATION insurance please be aware

that your insurance may require a referral from your PCP or treating physician. You will be responsible

for making sure we have that documentation. Without the proper documentation your insurance

company may not pay for your treatment and you would be responsible for the payment. You are

required to pay any co pays or deductible amounts at the time of service.

FMLA/DISABILITY FORMS

The office will need 7-10 business days to complete any FMLA paperwork or disability forms. There is

a $50.00 fee for filling out this paperwork. This is Not covered by your insurance company.

I have read the Patient Financial Policy and agree to abide by its terms as well as authorize my insurance

company to forward the Explanation of Benefits and related payments directly to the physician office.

Patient or Legal Guardian Signature Date

Printed Name

J. KEVIN KAUFMAN, M.D., F.A.C.S.Neurological & Complex Spine Surgery Hurst/Lancaster/Farmers Branch 809 W. Harwood, Suite 202 Hurst, Texas 76054 P: 817-377-0143 F: 817-377-0173

CONSENT TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION (PHI)

I AUTHORIZE Dr. J. Kevin Kaufman to obtain and use protected health information from other providers and disclose my medical information for the purposes of Treatment, Payment and Health Care Operations.

Treatment includes activities performed by a health care provider, nurse, office staff, and other types of health care professionals providing care to you, coordinating or managing your care with third parties, and consultations with and between other health care providers. This consent includes treatment provided by any physician who covers my/our practice by telephone as the on-call physician/nurse practitioner. Payment includes activities involved in health determining your eligibility for health plan coverage, billing, and receiving payment for your health benefit claims, and utilization management activities which may include review of health care services for medical necessity, justification of charges, pre-certification and pre-authorizations. Health Care Operations includes the necessary administrative and business functions of our office.

I further authorize Dr. J. Kevin Kaufman, to use and disclose my PHI (Protected Health Information) to the persons listed below:

I understand that I have the right to revoke this consent provided that I do so in writing, except to the extent that Dr. J. Kevin Kaufman has already used or disclosed the information in reliance on this consent.

Signature of Patient: ____________________ _

Signature of Legal Guardian: _________________ _

Date: _____________ _

J. KEVIN KAUFMAN, M.D., F.A.C.S.Neurological & Complex Spine Surgery Hurst/Lancaster/Farmers Branch 809 W. Harwood, Suite 202 Hurst, Texas 76054 P: 817-377-0143 F: 817-377-0173

PHYSICIAN-PATIENT AGREEMENT

Dr. Kaufman and staff are prepared to provide you with comprehensive health care. This care will

include:

• Scheduled visits with Dr. Kaufman and/or one of the nursing staff, who will serve as the

coordinator of your medical care.

• Medication if needed as prescribed by Dr. Kaufman

• Consultations with other care providers as requested by Dr. Kaufman

• Diagnostic and treatment procedures as ordered by Dr. Kaufman

To provide appropriate medical care, your cooperation is necessary. Your cooperation will be

demonstrated by your agreeing and adhering t the following:

I will notify the clinic at least 24 hours prior my appointment time if I need to cancel or reschedule an

appointment.

I will participate in the evaluation and treatment plan as agreed to with Dr. Kaufman

I will inform Dr. Kaufman or staff about all health care and medications I receive from sources other than

Dr. Kaufman and agree to any communication between health care providers about my care.

I along with my family/friends will treat the staff with respect and demonstrate that respect by

refraining from loud, abusive, or threatening language or behavior in the office or on the phone.

My signature below indicates my agreement with this plan.

Signature Date

J. KEVIN KAUFMAN, M.D., F.A.C.S.Neurological & Complex Spine Surgery Hurst/Lancaster/Farmers Branch809 W. Harwood, Suite 202 Hurst, Texas 76054 P: 817-377-0143 F: 817-377-0173

I acknowledge and agree that J. Kevin Kaufman, M.D. and any affiliates or vendor

thereof including collection or billing companies, may contact me by telephone or

text message to any telephonic number I have provided to your and any other

telephone number associated with my account. This includes wireless or mobile

telephone numbers. I further agree that you may use any method of contact to

these numbers such as automated telephone dialing system or pre-rerecorded

messages. I also agree that I will notify the office if I have changed any of my

numbers.

Printed Name

Signature

Date

Name: -----------------

Oswest,y Disability Index

Section 1 - Pain Intensity

C I haw no pafn at Ute moment

C The pain Is w,y mRd at the moment

a The pain Is moderate at the moment

C The pafn Is fairly severe at the moment

a The pain Is very severe at the moment.

a The pain is the worst &naginabfe at the moment

Section 2 -Personal care (washing, dressing, etc.)

a I can look after mysetl normally but It Is very pafnfuL

a I can look after myself nonnatJy but It Is very pafnful.

0 II Is painful to look after myself and I am slow and careful.

a I need some help but manage most of mype,sonal care.

IJ I need help every day In most aspects of my personal care.

a I need help every day In most aspects of self-care.

a I do not get dressed. wash with dfflicutty, and stay In bed.

Section 3 • Lifting

C I can lift heavy weights without extra paln.

a I can lift heavy weights but ft gives extra pain.

C Pain prevents me from riffing heavy welghts off the floor. but I can

manage If they are corwenfently positioned (le. on a table).

C Pain prevents me from liftfng heavy weights, but I can manage fight to

medium weights If they are conven!enUy pos!tioned.

a I can lift onfyvery l!ght weights.

a I cannot lift or cany anything at all.

Section 4-Walklng

0 Pafn does not prevent me walkfng any distance. 0 Pain prevents me walking more than 1mlle.

a Pain prevents me wa1kfng more Chan 14 of a mRe.

C Pafn prevents me walking more than 100 yards.

a I can only walk using a stick or erutches.

C I am In bed most of the time and have to c,awl to Iha toilet.

Section 5 -Sitting

a I can sit in any chair as rong as I ffke.

a I can sft in my favorite chafr as long as I like.

a Pain prevents me from slttfng for more than 1 hour. 0 Pain prevents me from sitting for more than ¥.a hour. CJ Pain prevents me from sitting for more than 10

mfnutes.

a Paln prevents me from sitting at aH.

Section a-Standfng

a I can stand as rang as I want without extra pafn.

a I can stand as long as I want but it gives me extra pain.

o Pafn prevents me from standing more than 1 hour.

a Pafn prevents me from standing for more than ¥.a an hour.

a Pain prevents me from stand'ing for more than 10 minutes.

a Pain prevents me from standing at all.

Date: ___________ _

Section 7 -Sleeping

0 . My sleep Is never disturbed by pain.

CJ My sleep Is ogcasionalJy disturbed by pain.

a Because of pain, I haw less than 6 hours sleep.

O Because of pafn, I have ress than 4 hours sleep.

0 .Because of pafn. I have less than 2 hows sleep.

a Pain prevents me from sleeping at all.

section a-Sex life (It applicable)

a My sex life Is nmmaJ and causes no extra pain.

0 My sex life Is nonnal but causes some extra pain.

C My sex Ufe fs nearly nonnal but Is very painful.

a My sex life fs severely restrfct8d by pafn.

a My sex l!fe Is nearly absent because of pain.

a Pain prevents any sex fife at au.

Section 9-Social Life

a My social life is normal and cause me no extra pain.

a My social life Is nonnar but b1creases the degree of paln.

a Pain has no significant effect on my social l!fe apart from llmhingmy

more energetic rntmests. Le. sports.

Cl Pain has restricted my social life and I do not go out as often.

CJ Pafn has restricted SOCial IIfe to my home.

a I have no soda! life because of pain.

section 10-Travellng

Cl I can travel anywhere without pain.

Cl I can travel anywhere but It ghles extra pafn.

Cl Pain Is bad bUt I manage Journeys of over two hours.

Cl Pain restrfcls me to short necessary Joumeys under 30 mfnutes.

Cl Pafn prevents me from traveltng except to receive treatment

Section 11 .. Previous Treatment

Over the past three months have Y.CJU received treatment, tabfets or

med!dnes d any kind for your baek or leg pain? Please ch8Ck the

appropriate box.

IJ No

Cl Yes (if yes. plaase state the type of treatment you have received)

Name: ___________________ Date: _____________ _

Neck Disablllty Index

This qwstlonna/re has been designed to givs ths doctor information as to how your neck pain has affected your ability to manage in

everyday Hie. Please answer every section and mark in each section only the ONE box which applies to you. We realize you may consider that two of the statements In any one section relate to you, but please Just mark the box which most closely describes your problem.

Section 1 - Pain lntenslty Cl I have no pain at the moment. (0) Cl The pafn fs very mffd at the moment (1) Cl 11le pafn Is moderate al Ute moment. (2) Cl The pafn Is fafrly severe at lhe moment. (3) Cl TIie pafn Is ve,y severe at lhe moment (4) Cl The pain Is the worst Imaginable at the moment (5)

Section 2- Personal Care (Washing, Dressing, etc.) Cl I can raok after mysett normally without causing extra pafn. (0) Cl I can look after myself nonnaRy but It causes extra pain. (1) Cl It Is pafnful to rook after myself and I am slow and careful. (2) IJ I need some help but manage most of my personal care. (3) a I rmed help every day in most aspects of self care. (4) Cl I do not get cftessed. I wash with dffficutty and Slay In bed. (5)

Section 3 - Ufling

Cl I can Ifft heavy wefghts without extra pafn. (0) CJ I can lift heavy wetghts but a gives extra pafn. (1) Cl Pain prevents me from llftlng heavy wafghts off the ffoor, but I can

manage ff they are convenfenUy posft!oned, for example on a table. (2) IJ Pain prevents me from liftfng heavy weights, but I can manage light 10

medium wefghts ff they 818 convenfently positfoned. (3) Cl I can llft ve,y Ught wafgtds. (4) Cl I cannot [1ft or carry anythfng at an. (5)

section 4- Readlng Cl I can read as much as I want to with no pafn fn my neck. (0) 0 I can read as much as I want to with slfght pafn tn my neck. (1) Cl I can read as much as I want with moderate pain fn my neck. (2) 0 1 cannot read as much as I want because of mocferate pain rn my neck.

(3) CJ I can hardly read at aD because cf .,.,era pain In my neck. (4) 0 I cannot read at ml. (5)

Section 5- Headaches Cl I have no headaches at all. (0) IJ I have slight lleadaches Chat come Infrequently. (1) a I have moderate headaches wllich come fnfrequently. (2) Cl I have moderate headaches which come frequently. (3) Cl I have severe headaches whfch come frequently. (4) Cl I have headaches armost all the lime. (5)

Section 6 -Concentration Cl I can concentrate fully when I want to with no dlfffculty. (0) Cl I can concentrate fully when I want to with slight dlfflCUlty. (1) 0 I have a fair degree of difficulty In concentratfng when I want to. (2) IJ I have a rot of dlfflculty fn concentratfng '*811 1 want to. (3) Cl I have a great deal of dtfflculty ln concentrating when I WBJ)t to. (4) C I cannot concentrate at au. (5)

section 7 -Work

Cl I can do as much work as I want to. (0) a I can do my usual work, but no mom. (1) C I can do most of my usual work, but no more. (2) Cl I cannot do my usual work. (3) Cl I can hardly do any work at atL (4) C I cannot do any work at aD. (5)

Section a- Driving C I can drive my car without any neck pain. (0) O I can drive my car as rang as I want with sffght pafn fn my neck. (1) CJ I can drive my car as long as I want wfth mcc:ferate pafn rn my neck. (2) a I cannot drive my car as long as I want because of moderate pafn fn

my neck. (3) Cl I can hardly drive at au because of severe pafn In my neck. (4) CJ ·, cannot drive my car at aD. (5)

Section 8 - Sleeping C • I have no In>� sleeping. (0) Cl My steep Is sl!ghtly disturbed (less than 1 hour sleepless). (1) IJ My sleep Is mildly disturbed (1·2 haunt s!eep!ess). (2) C My sleep is moderately disturbed (2-3 hoWs sleepless). (3) Cl My steep is greatly disturbed (3-5 flouls sfeepless). (4) Cl My sleep Is completely disturbed (S-7 hours sleep!ess). (5)

Section 10-Recreation

Cl I am ab!e to engage in all my recreation activHfes wfth no neck pafn at aD. (0)

0 I am ab!e to engage ln an my recreation actMtfes, with some pafn fn myneck. (1)

Cl I am able to engase fn most. but not all. of my usual recreatlan activffles because of parn In my neck. (2)

CJ I am abfa to engage In a few er my usual recreation activities because of pain fn my rtedc. (3)

CJ I can hardly do any� acttvit!es because of pain In my neck. (4)

Cl I cannot do any recreallon actMties at aU. (5)

D-4 5-14 15-24 25-34 >35

No dlsablllty MIid dfsablllty Moderate dlsabUlty Severe dlsablllty Comprete dlsabDlty

\ 972 n 7 ... " lti

Thank You For Choosing Southern Star Pharmacy

Please take a few minutes to read the following information about the process of filling your prescnp!lon

In order to ensure a positive outcome, 1t is important that you follow the below instructions

When Will I Receive My Medication'"'

Expect to receive a call from Southern Star Pharmacy within I business day

Once we have obtained all required information, we will process your prescnption and if applicable, any

compound will be custom prepared within 24 hours.

We will apply any manufacture coupons applicable to your medication to give you the lowest pnce.

You can expect to receive your medication through Courier. USPS or FedEx within 1 business day after

speaking with the Pharmacy Representative

A signature will be required to receive your medication 1f it contains a controlled substance

What lnfonnat1on Will I Need?

When speaking with the Southern Star Pharmacy Representative. you will need to provide general

demographics, any known allergies, and your prescription drug card

You can text a picture of your prescription card to 844.290.7034

If this 1nformat1on 1s not available, you can provide the name and phone number of the pharmacyyou

normally use

Why Switch to Southern Sta, Ptnrrnacy?

• We provide unparalleled, concierge level customer service.

• Text us any time with any questions, there is always a pharmacist ready to reply at 844.290. 7034.

• Skip waiting in line- we deliver to your doorstep.

• If there is a coupon available, we will activate it for you and apply it to your medications.

• We work with youi insurance earner and phys1c1an to ensure your med1cat1on 1s covered

• No insurance- no p, obi em we have special pricing for all of our cash paying patients

Who 1s Southern Sta, Ph"rn--2cy?

We are a community pharmacy whose top priority is the care and service of our patients We stnve to enhance our

patients' experience through superior patient education, excellent customer service, medication availab11ity and cost

savings We are located in Farmers Branch, Texas. If you live locally you are welcome to pick up your prescription or

we will deliver it to you. We look forward to helping you fulfill your prescribed plan

Our Patient Care Team is available Monday through Friday 9:00 a.m. to 5:30 p.m. CST.

We are happy to discuss any questions that you may have.

Call or Text Us Toll-Free At 844.290. 7034

Patient Name: ___________________ DOB: __________ _

We, at or. Kaufman's Office are very pleased that you have chosen us as your Neurosurgeon • Wewant to provide you with exceptional care, ease of convenience, and a great experience therefore we have chosen Southern Star Pharmacy as our preferred specialty pharmacy.

(See next page for pharmacy services and benefits.)

Please sign below to have your prescriptions sent to Southern Star pharmacy and delivered directly to

your door step at no additional cost.

Southern Star Pharmacy

14444 W Beltwood Parkway, Suite 150

Farmers Branch, TX 75244

_ Yes, deliver my medications directly to my home at no additional cost.

Signature __________________________ Date ____ _

_ No, I decline to use the above named pharmacy please send my prescriptions to the pharmacy below.

Pharmacy Name _____________________________ _

Pharmacy Address ____________________________ _

Pharmacy Phone number ___________________________ _

Pharmacy Fax number ____________________________ _

Signature __________________________ Date _____ _