Skip to main content
865.692.1610
865.692.1619
7714 Conner Road, Suite 107 Powell TN 37849
Leave A Review
Close Search
Breast Cancer Treatment SurgeonBreast Cancer Treatment Surgeon
search
Menu
  • Home
  • Breast Cancer
    • Hidden Scar Surgery
    • Inflammatory Breast Cancer
    • Triple Negative Breast Cancer
    • Invasive Ductal Carcinoma
    • BRCA Gene
    • Lumpectomy
    • Fibrocystic Disease of Breast
    • Mammogram
    • Mastectomy
    • Genetic Testing
    • Genetic Counseling
    • Terms Glossary
  • Patient Resources
    • Article Library
    • Video Library
    • Doctor Referrals
    • Patient Forms
      • Breast Care Consultation
      • General Surgical Consultation
      • Genetic Counseling
    • External Resources
      • myGeneHistory
      • 5 Questions to ask the Radiologist
      • Patient Portal
  • About
    • Aaron G. Margulies, MD, DABS
    • Imelda G. Margulies, MSN, FNP-BC
  • Schedule Appointment
  • search

Breast Care Consultation

Patient Form

View PDF Version

"*" indicates required fields

Appointment Information:

Patient: ______________________________

Date: ________________________________

Time: ________________________________

North Office Location
7714 Conner Road Suite 107
Knoxville, TN 37849
West Office Location
Tennova Turkey Creek Medical Center
10810 Parkside Drive Suite G-11
Knoxville, TN 37934
Jefferson City Location
Jefferson Memorial
120 Hospital Drive
Suite G-50
Jefferson City, TN 37760
Newport Location
Newport Medical 434 Fourth Street Suite 301
Newport, TN 37821

Thank you for choosing our office for your surgical consultation. To assist us in providing you with the best care possible, please bring the following with you to your appointment:

  • Insurance cards and Photo ID
  • Medication list including dosages
  • Complete the attached forms
  • Imaging disc and coinciding reports (i.e., Breast Imaging, MRI, or CT scans)

We value your time and want to provide you with a comprehensive and in-depth evaluation. To do so, please allow up to two hours in our office for your appointment. If you have any questions prior to your scheduled appointment, please contact our office at 865-692-1610. For more information, you can also go to our website, www.aaronmd.com. If your insurance has been purchased through the Affordable Healthcare Marketplace, please verify with your carrier that Dr. Margulies is an “in-network provider” by calling the number on the back of your insurance card. We look forward to meeting you and providing you with compassionate surgical care that you can trust.

Sincerely,


Aaron G. Margulies, MD, FACS
Breast Surgical Oncologist / General Surgeon


Patient Information

Address*

Phone Numbers

Preferred Method of Contact

Emergency Contacts

Name
Relation
Phone
 
Do you consent for our office to leave a voice message if needed?*
May we contact and share medical information with your emergency contacts if needed?*
Would you like an email for sign-up information to Dr. Margulies’ blog on Breast Cancer?*
Would you like an email invite to register an account on our patient portal?*
Which office is most convenient for you?*
If you are a Breast Care Patient, do you give consent for Dr. Margulies to discuss your case with other physicians?
If you are a Genetics Patient, do you give consent for our office to release or obtain copies of your genetic testing?

Insurance

If your insurance carrier is through your spouse or someone else, please complete the following.

Treating Physicians

Gynecologists

Pharmacy Information

City

By signing below, I verify that all the information above is correct. I also verify that I have been offered and have reviewed a copy of the Patient Privacy Notice required by HIPAA and understand my right to privacy as a medical patient of Aaron G. Margulies MD, PLLC.

Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY

Breast Intake Questionnaire

Give a brief description.

Allergies and Medical History

Medical History/Problems
List any medical problems that other doctors have diagnosed.
History of Sleep Apnea*
CPAP*
Oxygen*
Past Surgeries
Daily Medications and Supplements
Medication Allergies
Have you been vaccinated for COVID-19?*

Social History

Tobacco Use
Alcohol Use
Any family history of bleeding disorders?
Have any family members been instructed to never use anesthesia?

Risk Calculations

Ashkenazi Jewish Heritage?*
Hysterectomy:*
Ovaries Present?*
Oral Contraceptive Use:*
Hormone Replacement:*
Previous history of any Breast Biopsies:*
Do you have any personal or family history of the following types of cancer? If so, check the appropriate boxes.

Family History

Ashkenazi Jewish?

Please list all members of your family alive or deceased (regardless of cancer).

Indicate who (including yourself) has had cancer - especially breast, ovarian, pancreatic, and prostate.
You
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
Daughters
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 
Sons
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 
Sisters
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 
Brothers
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 
Mother
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
Father
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
Grandmother (Mother's Side)
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
Grandfather (Mother's Side)
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
Aunts (Mother's Side)
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 
Uncles (Mother's Side)
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 
Grandmother (Father's Side)
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
Grandfather (Father's Side)
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
Aunts (Father's Side)
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 
Uncles (Father's Side)
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 
Other Relatives
Relation
First Name
Alive (Age)
Deceased (Age)
Cancer (Y/N)
Type
Age at Diagnosis
 

Financial Responsibility

At the office of Aaron G. Margulies, MD, PLLC, we strive to give you the best possible care. In order to serve this purpose, it is important that our patients understand the process of reimbursement. Please read this Financial Responsibility Form and sign to acknowledge that you understand your accountability.

Insurance Coverage

It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations, as well as, authorization requirements. This information can be obtained by contacting your insurance carrier.

We attempt to verify that your coverage is valid at the time of your visit. However, if your coverage is not in effect at the time of the visit, the financial responsibility for any payment due will be yours.

*If you have any changes in your insurance coverage you must notify us prior to your appointment.

Deductibles, Coinsurance and Copayments

The deductible is determined by your individual contract with your insurance carrier. You are responsible for your deductibles, copayments, and coinsurance. Your insurance company expects us to collect them from you at the time of service. Understand that you will be expected to pay deductibles, coinsurance and copayments, when this applies.

Non-covered Services and Medical Necessity

All patients are responsible for account balances if their insurance carrier denies payment for services rendered because they were stated as “non-covered services” or deemed as “medically unnecessary.” To avoid this, please check with your insurance carrier prior to receiving any treatment or services.

By signing below, I authorize the release of any medical information necessary to process insurance claims filed to my insurance carrier on my behalf or on the behalf of my dependents. I authorize payment for medical benefits to be made directly to my physician for services rendered at the office of Aaron G. Margulies, MD, PLLC.

I certify that I have read the above disclosure statements, understand my responsibilities, and agree to the terms written above.

Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

Copyright © 2020 Dr. Aaron Margulies. All Rights Reserved.
Knoxville Web Design by Make Me Modern.
Breast Cancer Treatment Surgeon Knoxville, TN

Copyright © 2022 Dr. Aaron Margulies. All Rights Reserved.
Knoxville Web Design by Make Me Modern.

    Close Menu
    865.692.1610
    865.692.1619
    7714 Conner Road, Suite 107 Powell TN 37849
    Leave A Review
    • Home
    • Breast Cancer
      • Hidden Scar Surgery
      • Inflammatory Breast Cancer
      • Triple Negative Breast Cancer
      • Invasive Ductal Carcinoma
      • BRCA Gene
      • Lumpectomy
      • Fibrocystic Disease of Breast
      • Mammogram
      • Mastectomy
      • Genetic Testing
      • Genetic Counseling
      • Terms Glossary
    • Patient Resources
      • Article Library
      • Video Library
      • Doctor Referrals
      • Patient Forms
        • Breast Care Consultation
        • General Surgical Consultation
        • Genetic Counseling
      • External Resources
        • myGeneHistory
        • 5 Questions to ask the Radiologist
        • Patient Portal
    • About
      • Aaron G. Margulies, MD, DABS
      • Imelda G. Margulies, MSN, FNP-BC
    • Schedule Appointment