CITY STATE ZIP CITY STATE ZIP COUNTY USA OTHER PATIENT S CONTACT INFORMATION HOME PHONE # DAY PHONE # ALTERNATE PHONE ADDRESS

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1 35 Casa Street Suite 130 San Luis Obispo, CA P: F: Patient Information Please provide us with your insurance and valid ID PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING ADDRESS PATIENT S PHYSICAL ADDRESS STREET OR PO BOX CITY STATE ZIP CITY STATE ZIP COUNTRY COUNTY COUNTRY COUNTY USA USA OTHER OTHER PATIENT S CONTACT INFORMATION HOME PHONE # DAY PHONE # ALTERNATE PHONE ADDRESS PATIENT S EMERGENCY CONTACT INFORMATION NAME ADDRESS RELATIONSHIP CONTACT PHONE NUMBER PATIENT S ADDITIONAL INFORMATION MOTHER S MAIDEN NAME RACE LANGUAGE RELIGION ASIAN ENGLISH PACIFIC ISLANDER SPANISH BLACK OTHER CHURCH UNKNOWN NATIVE AMERICAN WHITE OTHER ETHNICITY MARITAL STATUS STUDENT STATUS VETERAN SMOKER HISPANIC ANNULLED FULL-TIME YES YES NON-HISPANIC POLYGAMOUS NOT A STUDENT NO NO UNKNOWN DIVORCED PART-TIME SINGLE INTERLOCUTORY WIDOWED LEGALLY SEPARATED LIFE PARTNER UNKNOWN MARRIED REFERRING PHYSICIAN PRIMARY CARE PROVIDER/PHYSICIAN NAME NAME CITY, STATE, AND ZIP CITY, STATE, AND ZIP OFFICE PHONE NUMBER OFFICE PHONE NUMBER FAX NUMBER FAX NUMBER RESPONSIBLE PARTY S INFORMATION (if different than above) NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SSN BIRTH SEX RELATIONSHIP TO PATIENT RESPONSIBLE PARTY S BILLING/MAILING ADDRESS STREET OR PO BOX RESPONISBLE PARTY PHYSICAL ADDRESS CITY STATE ZIP CITY STATE ZIP HOME PHONE NUMBER ADDRESS REV. 2/10/15

2 35 Casa Street Suite 130 San Luis Obispo, CA P: F: PATIENT S EMPLOYER NAME OF EMPLOYER EMPLOYER S ADDRESS (Street, City, State and Zip) TYPE OF BUSINESS Patient Information Please provide us with your insurance and valid ID LOCAL ADDRESS CORPORATE ADDRESS COUNTY OCCUPATION EMPLOYMENT STATUS FULL-TIME PART-TIME RETIRED DISABLED PRIMARY INSURANCE NAME OF SUBSCRIBER (Last, First, Middle) SUBSCRIBER S ADDRESS (Street, City, State and Zip) SUBSCRIBER S SOCIAL SECURITY NUMBER NAME OF INSURANCE COMPANY WORK PHONE RELATIONSHIP TO PATIENT POLICY NUMBER SUBSCRIBER S OF BIRTH GROUP NUMBER ADDRESS OF INSURANCE COMPANY (Street, City, State, and Zip) SECONDARY INSURANCE (if applicable) NAME OF SUBSCRIBER (Last, First, Middle) SUBSCRIBER S ADDRESS (Street, City, State and Zip) RELATIONSHIP TO PATIENT EFFECTIVE POLICY NUMBER EXPIRATION SUBSCRIBER S SOCIAL SECURITY NUMBER NAME OF INSURANCE COMPANY SUBSCRIBER S OF BIRTH GROUP NUMBER ADDRESS OF INSURANCE COMPANY (Street, City, State, and Zip) EFFECTIVE EXPIRATION ASSIGNMENT AND RELEASE I, the undersigned, have insurance with and assign directly to Dr. all medical benefits. I understand that I am financially responsible for all charges incurred. A copy of the back and front of my insurance card is required for billing purposes. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions. Sometimes healthcare information may be used for research, all such information is anonymous, and patient confidentiality is maintained. If you do not want any information to be used for research please check here. Signature of Insured Date CONSENT FOR TREATMENT I, the undersigned hereby authorize and give consent to Dr. for any x-rays examinations, laboratory tests, and treatment rendered to the patient named above. Signature Date MEDICARE AUTHORIZATION Please be advised, it is the patient s responsibility to ensure that the physician they see is contracted with their insurance plan. REV. 2/10/15

3 PATIENT S INFORMATION NAME (Last, First, Middle) PREFERRED PHARMACY (Name, Address, Phone Number) BIRTH BACK UP PHARMACY (Name, Address, Phone Number) REASON FOR VISIT Patients Injury/Illness: Onset Date: Rate of Pain(0= no pain; 10= most severe) ALLERGIES (Medication(s), Environmental Issue(s), and Food(s)) Item(s) that you are allergic to: Reaction(s) you have had from the Allergen, you are allergic to: MEDICATIONS AND SUPPLEMENTS THAT YOU TAKE ON REGULAR BASIS Drug Name (Brand name, or generic name) Dosage Times taken within 24 Hours Reason for taking Medication REV. 12/18/2014 cl

4 PATIENT INFORMATION NAME (Last, First, Middle) BIRTH REVIEW OF SYSTEMS CONSTITUTIONAL: Chills Weight Gain Fatigue Weight Loss Fever Malaise Night Sweats Weakness HEAD, EYES, EARS, NOSE, AND THROAT: Ear drainage Ear pain Eye discharge Eye pain Hearing loss Nasal drainage Sinus pressure Sore throat Eye Redness RESPIRATORY: Chronic cough Cough Known TB exposure Shortness of breath Wheezing CARDIOVASCULAR: Chest Pain Claudication Edema Palpitations GASTROINTESTINAL: Abdominal Pain Blood in stools Change in stools Constipation Diarrhea Heartburn Loss of appetite Nausea Vomiting METABOLIC/ENDOCRINE: Cold Intolerance Heat Intolerant Polydipsia Polyphagia NEUROLOGICAL: Dizziness Extremity numbness Extremity weakness Gait disturbance Headache Memory loss Seizures Falls PSYCHIATRIC: Anxiety Depression Insomnia INTEGUMENTARY (SKIN): Brittle hair Brittle nails Rash Hives Skin Lesion Pruritus HEMATOLOGIC: Easy bleeding Easy bruising Lymphadenopathy GENITOURINARY: Dysuria Hematuria Polydipsia Urinary frequency Urinary incontinence Urinary retention REPRODUTIVE: Abnormal Pap Dysmenorrhea Dyspareunia Hot flashes Irregular menses Discharge Musculoskeletal: Back pain Joint pain Joint swelling Muscle weakness Neck pain IMMUNOLOGIC Contact allergy Environmental allergies Food allergies Seasonal allergies OTHER CONDITIONS NOT NOTED: REV. 12/18/2014 cl

5 CHRONIC PROBLEM LIST Chronic Problem Onset Date PAST MEDICAL/SURGICAL HISTORY Procedure Year FAMILY HISTORY (Please List only Mother, Father, Brother, and Sister) PATIENT ADOPTED NO RELEVANT FAMILY HISTORY Diagnosis Family Member Name Age Onset or Age Death Comments SOCIAL HISTORY Uses Tobacco: Currently Never Formerly Unknown Type: Chewing Cigar Cigarettes Pipe Smokeless Snuff Recreational Drug Use: Currently Formerly Never Unknown Marijuana IV Units/Day: Years Used: Other Occupation: Alcohol Use: Yes No Formerly - Year Quit If "YES" Type of Alcohol Frequency When was Last Drink Caffeine Use: Yes No Type Amount Daily Marital Status: Number of Children: Vaginal How Many: C-Section How Many: WHEN WAS YOUR LAST: Immunizations: Pneumonia Tostavax Flu Vaccine Tdap TB Skin Test/PPD HPV Human Papilloma Virus-Gardasil Diagnostic Procedures: Mammogram Eye Exam DXA IVP PAP Smear EKG Stool Blood Test MRI Scan Colonoscopy CT Scan EGD Pulmonary Function Test PSA Aortic Ultrasound Chest Xray Gallbladder Sonogram ECHO Angiogram/Cath Curated Duplex/Ultrasound Treadmill Patient's Printed Name Patient's Signature Date Signed REV. 12/18/2014 cl

6 Heidi Freeman, M.D. Christine Lopoplo, M.D. Heidi Sungurlu, D.O. Cynthia Scott, R.N.P. OB-GYN 35 Casa Street, Suite 130 San Luis Obispo, Ca Phone Fax IN AFFILIATION WITH AUTHORIZATION TO DISCLOSE MY HEALTH INFORMATION AND TRANSFER MY MEDICAL RECORDS PHYSICIAN/FACILITY NAME: PHONE: FAX: PATIENT NAME: OF BIRTH: MY AUTHORIZATION: Please transfer the following health information: Pap Smear Results Lab Results Diagnostic/Imaging Results Other: You may disclose this information to: Heidi Freeman, M.D. Christine Lopopolo, M.D. Heidi Sungurlu, D.O. Cynthia Scott, N.P. 35 Casa Street Suite 130 San Luis Obispo CA Ph Fax Patient or legally authorized individual Signature Printed Name Date Relationship to Patient For use by Dr. Freeman and Dr. Sungurlu Medical Center, Inc. only below this line () Signature Verified () Authorization logged in patient s chart. EMPLOYEE SIGNATURE: Rev.8/2015

7 Name: Patient # Use and Disclosure of Medical Information Acknowledgment, Notice of Privacy Practices The Department of Health and Human Services established the HIPAA Privacy Rule to protect the privacy of the identifiable health information. In accordance with this Rule, First Choice Physician Partners has prepared a Notice of Privacy Practices that is given to patient at their first visit after April 14, Acknowledgement I understand that First Choice Physician Partners may share my health information for treatment, billing, and healthcare operations. I have been given a copy of the organization s Notice of Privacy Practices that describes how my health information is used and shared. I understand that First Choice Physician Partners has the right to change this notice at any time. I may obtain a current copy by contacting the medical group s Privacy Official. My signature below constitutes my acknowledgment that I have been provided with a copy of the Notice of Privacy Practices. Print Name Signature of Patient or Legal Representative Date If signed by legal representative, relationship to patient: Check here if patient refuses to sign. FCPP Employee Initial Disclosures to Family and Friends With your permission, we may disclose your relevant health information to family members, friends, or other persons you identify below. This permission may be revoked by you at any time. Name Relationship Phone Number Print Name Signature of Patient or Legal Representative Date

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