"*" indicates required fields Step 1 of 9 11% CommentsThis field is for validation purposes and should be left unchanged.Please Select a Location*Select oneAshevilleHendersonvilleName* First Middle Initial Last Sex at Birth*Select oneMaleFemaleGender You Identify As*Select OneMaleFemaleOtherSSN*Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone Number*Work PhoneEmail* Preferred Language* Primary Care Provider Name*Primary Care Provider Location*Primary Insurance Provider*Medicare?* Yes No Name Displayed on Card* First Last Policy ID*Group ID*Plan IDPolicy Holder's Name* First Last Relationship to Patient*Select OneSelfSpouseParentChildOtherPolicy Holder's Date of Birth* MM slash DD slash YYYY Policy Holder's Employer*Do you have Secondary (Supplemental) Insurance?* Yes No Secondary Insurance Provider*Medicare?* Yes No Name Displayed on Card* First Last Policy ID*Group ID*Plan IDPolicy Holder's Name* First Last Relationship to Patient*Select OneSelfSpouseParentChildOtherPolicy Holder's Date of Birth* MM slash DD slash YYYY Policy Holder's Employer* Height (Feet)*Please enter a number from 1 to 7.Height (Inches)*Please enter a number from 0 to 11.Weight (lb.)*Are you currently pregnant?* Yes No Do you take any blood thinners?* Yes No What is the name of your blood thinner and managing provider?*For example: wrfarin/coumadin, Plavix/clopidogrel, lovenox/enoxaparin, Xarelto/rivaroxaban, Eliquis/apixabanDo you have a Cardiac Defibrillator?* Yes No Do you use continuous oxygen?* Yes No How many liters do you use?* Are you taking Dofetilide (Tikosyn)?* Yes No Has anesthesia given you a letter about a difficult airway or have a history of difficult intubation?* Yes No Do you take weight loss medication?* Yes No Can you walk up a flight of stairs without chest pain or shortness of breath?* Yes No In last 6 months, any symptoms or newly diagnosed issues for your heart and/or lungs?* Yes No Do you have any further workup planned?* Do you have an Abdominal Aortic Aneurysm?* Yes No f yes, is your AAA >5cm?* Yes No Have you had an evaluation for your AAA in the last 12 months?* Yes No Do you have severe aortic stenosis?* Yes No Do you have idiopathic thrombocytopenia, Platelet clotting disorder, or any other blood disorder?* Yes No Have you had or planning to have a heart or lung or Kidney transplant?* Yes No Do you have decreased kidney function?* Yes No Do you have diabetes?* Yes No Do you take insulin or other diabetes medications?* Yes No Are you on dialysis or have you been told you will need dialysis?* Yes No Any major surgeries in the last 3 months, including abdominal or gastrointestinal related?* Yes No Do you have a seizure disorder?* Yes No When was your last seizure?*Any major health changes or hospitalizations or ER visits in the last 6 months?* Yes No Have you had any head or neck surgeries/injuries that restrict your range of motion?* Yes No Have you ever had radiation to your head or neck area?* Yes No Are you currently on Chemotherapy?* Yes No Do you have a port for IV or blood access?* Yes No Do you require an ultrasound to find IV access?* Yes No Have you been treated for C.Diff in the past and currently having symptoms?* Yes No Have you had or are being treated for diverticulitis in the last 6 weeks?* Yes No Do you have narcolepsy?* Yes No Any mobility issues we should be aware of?* Yes No Any health issues we have not discussed that may interfere with your procedure?* Yes No Do you have Spasmodic Dysphonia?* Yes No Do you have Autonomic Dysreflexia?* Yes No Do you have Addison's Disease?* Yes No Does the patient reside in a skilled nursing facility or assisted living?* Yes No
