For Our Patients

Forms:

In order to allow our patients to spend less time in our waiting room filling out forms, we have included all the forms you will need to fill out right here on our web site. [Please note that these forms are in PDF format and may take a few moments to download. If you don't have Acrobat Reader, download your free copy here.]

Registration Forms

Please read Before Your Visit: General Information For Our Patients before your first visit to our office. It provides important information about our office policies and appointment procedures. In addition, we encourage you to print out the each of the forms below, fill them out in the comfort of your own home or office and then simply bring them with you to your visit.

• Patient Registration Information Form (2 pages)
• Patient Financial Responsibility Form
• Medical History (4 pages)
• Medication Sheet
• Authorization of Use and Disclosure of Protected Health Information
• Medical Records Release Authorization
• Acknowledgement of Receipt of Notice of Privacy Practices (HIPPA)
  
  

Additional Patient Forms

At some point during your relationship with Urology Associates of Danbury, you may find that you need additional forms for various reasons. By downloading those forms from the website, you will save yourself a telephone call to our office. Simply print the form and complete it in the comfort of your own home and then return it to our office.

• Consent to Treat Minor Child
• Second Opinion Consultations

Privacy and The Health Insurance Portability and Accountability Act (HIPAA)

The goal of Urology Associates of Danbury, P.C. is to be HIPAA compliant in all aspects of the practice. For your information, below is our Notice of Privacy Practices along with a summary of this notice. Please take a few moments to review this notice and if you have any questions regarding the notice, please contact our Practice Administrator.

• Notice of Privacy Practices
• Summary of Our Notice of Privacy Practices
• Acknowledgement of Receipt of Notice of Privacy Practices (HIPPA)

Test Preparations

For the convenience of our patients, we have attempted to give a brief summary of what you will need to do if you are having tests which have been ordered by your physician. Simply look at the chart below to find the test you have been instructed to take and then look at the corresponding test preparations and instructions.

If you have any questions about these instructions, please phone our office at 203-748-0330 or, alternatively, contact the facility where your test will be performed.

Test	Preparations
Renal Ultrasound	Nothing by mouth 4 hours prior to exam
Bladder Ultrasound	1 hour before your exam empty your bladder. Then drink 24-32oz of water. It is important to keep your bladder full for the exam. Please try not to go to the bathroom until the ultrasound is completed. If your bladder is uncomfortably full when you arrive for your examination, tell the receptionist, at which time you will be given further instructions
CT Stone Study	Nothing to eat 4 hours prior to exam.
CT Abdomen and/or Pelvis	Nothing by mouth 4 hours prior to exam
Intravenous Pyelogram (IVP)	Danbury Hospital or Danbury Diagnostic Imaging (DDI): Start a liquid diet 24 hours prior to test (jell-o, soda, juice, clear broth). At 6pm the night before, drink 1 bottle of Magnesium Citrate (available at any pharmacy). The morning of the exam it’s a clear liquid diet. Nothing by mouth 4 hours prior to exam. After the test, drink plenty of fluids. Northeast Radiology: (www.nerad.com) Start a clear liquid diet 24 hours prior to exam. At 5pm the night before drink 60ml of Magnesium Citrate (available at any pharmacy). At 10pm the night before take 4 tablets of Bisacodyl (Ducolax). Nothing to eat or drink after midnight. Housatonic Valley Radiology: At 3pm the day before your study take 3 Ducolax tablets (available at any pharmacy). At supper begin a liquid diet. On the day of the exam, no breakfast.

Surgery Instructions

• The surgery staff will call you the afternoon or evening prior to your procedure to give you instructions and to let you know what time to be at the hospital. If you will be traveling or unreachable by telephone, you can call Danbury Hospital at 203-797-7823 after 12 noon the day before your surgery to obtain these instructions.
  
  
• Do not eat or drink anything after midnight the night prior to your procedure. You may take approved medications the morning of your procedure with a small sip of water.
  
  
• Do not take any aspirin, anti-inflammatory, or blood thinner 7 days prior to your procedure. This includes Advil and ibuprofen, but you may take Tylenol. You should check with your primary care physician to assure that it is okay to stop these medications. If these medication cannot be stopped, contact us immediately.
  
  
• If you are taking any prescribed medications, you should address these medications with your primary care physician prior to your surgery.
  
  
• Please notify our office of any illnesses incurred 1 week prior to your surgery.
  
  
• Wear comfortable clothing. Do not wear any cologne, make-up, nail polish, and as little jewelry and take as little money as possible.
  
  
• Bathe or shower the evening before or the morning of your procedure.
  
  
• The morning of your procedure, check in at Danbury Hospital. If your procedure is on an outpatient basis, you will need someone to drive you home. Bring a list of all medications you take regularly to the hospital with you.
  
  
• If the patient is unable to sign the hospital consent, a legal guardian must be available for signature. You should also inform the hospital before your surgery of this fact by phoning them at 203-797-7823.
  
  
• Our office makes every effort to meet your insurance obligations with regards to pre-certifications however, it is in your best interests to familiarize yourself with your policy and to double check that you have the appropriate pre-authorization prior to the date of your surgery.
  
  
• If you do not have insurance or your insurance plan is not a contracted plan with our office, prior payment arrangements must be made with the Danbury Hospital Business office.