Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico (575) Fax: (575)

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1 Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico (575) Fax: (575) Patient Registration Form: (Please Print all Pertinent Information) Last Name First Name Middle Address City State Zip Home Phone Cell Phone SS# Date of Birth Sex: M or F Marital Status: S M W D Sep. Please circle one: Employed Not-Employed Retired Student Part-Time Student Employer Work Phone Number Employers Address City State Zip Emergency Contact Name and Number Referring Dr./ Family Dr. Name and Location of your Pharmacy Responsible Individual If Patient is Not the Guarantor for This Account Father, Mother, Spouse, Step Parent, Foster Parent, Etc. Last Name First Name Middle Address if different from above Home Phone Sex: M or F Date of Birth SS# Employer Employers Number Employers Address Insurance Authorization and Assignment All Patients: I request that payment of authorized insurance benefits be made on my behalf to Roswell Ear, Nose, Throat, & Allergy for any services furnished to me by that physician/supplier. I authorize any holder of Medicare information needed to determine these benefits payable for related services for myself or my dependent. I understand that I am responsible for any amount not covered by insurance. Beneficiary Signature Date Medicare Patients Only: I request that payment of authorized Medicare benefits be made of my behalf to Roswell Ear, Nose, Throat, & Allergy for any services furnished to me by that physician/supplier. I authorize any holder of medical information about me to release to the Heath Care Financing Administration and its agents any information needed to determine these benefits for the benefits payable for related services. Beneficiary Signature Date PRIVATE PAY PATIENTS: I understand that I am responsible for the billed amount. Signature Date

2 Date: Name: Date of Birth: Your approximate weight Chief Complaint: Surgical History: Dental History: TJM Y or N Ongoing dental problems Y or N Dentures: Full Y or N Partial Y or N Are you pregnant: Y or N Reaction to anesthesia: Y or N If yes: Local or General Do you have a history of drug abuse Y or N If so, what type: Medical History: List diagnosed medical problems: Lab or X-ray studies done- please list what, where, and approximate date: Social History: Married: Y or N If single, live alone: Y or N Ever smoked/chewed tobacco regularly Y or N How many packs per day how long Now Y or N Quit months/years ago Ever consume alcohol regularly Y or N Now Y or N How much: Family History: Please check this section carefully, Circling all the people with this disease: Prior allergy work-up Y or N Received shots Y or N When any benefit Y or N Allergies to medicines (list med and type of reaction): Current Medications: List type, dosage, and how often you take them. Please list all over the counter medicines and vitamins: Heart Disease: Stroke: Emphysema: Asthma: Diabetes: High Blood Pressure: Cancer: Type: Breast Colon Mouth Lung Pancreatic Brain Lymphoma Prostate Ovarian Leukemia Cervical Other:

3 REVIEW OF SYSTEMS PLEASE CIRCLE ANY THAT APPLY TO YOU GENERAL: HEAD AND EYES: ENT: Abnormal fatigue, weight loss or gain, sleeping problems Headaches, vision problems, glaucoma, blurred vision Hearing loss, noise in the ear, ear ache/infections, sinusitis, nasal congestion/drainage or snoring, hoarseness, laryngitis, sore throat, swallowing problems RESPIRATIORY: CARDIOVASCULAR: DIGESTIVE: MUSCULOSKELETAL: EXTREMITES: SKIN: BLOOD/LYMPHATIC: ENDOCRINE: ALLERGIC/IMMUNE: NEUROLOGICAL: PSYCHIATRIC: Emphysema, pneumonia, bronchitis, asthma, cough, shortness of breath, coughing up blood High blood pressure, abnormal pulse, chest pain, hear murmur, cardiac surgery Ulcers, abdominal pain, change in bowel habits, nausea, vomiting, jaundice, hiatal hernia, reflux symptoms Joint or bone pain, abnormal muscle weakness Arm or leg swelling Rashes, itching, lesions, hives Easy bruising or bleeding, anemia, prior to transfusions Diabetes or thyroid problems Sneezing, itchy watery eyes, Hx of Hepatitis, HIV, TB Seizures, stroke, paralysis, dizziness Anxiety, depression, psychiatric illness Please tell us anything (not listed above) that you feel might be important for your care: NAME: SIGNATURE: DATE:

4 ROSWELL EAR, NOSE, THROAT, & ALLERGY Patient Consent for E-Prescribing (Electronic Prescribing) I have been made aware and understand that the medical practices and offices may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my providers and my pharmacy. I have been informed and understand that my providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my provider to see this protected health information.!"#$%&'(!"&)$%&*+(,)-%"&.#$(/#(0.&1/#)2$3( 4$5#$+$%&"&)6$( ( 7"&$( 8)9$( ( 4$:"&)/%+1)5(&/(!"&)$%&( ;%&$#5#$&$#'()<(.&):)2$3( =)&%$++*(,)-%"&.#$( (

5 ROSWELL EAR, NOSE, THROAT, & ALLERGY 342 W. SHERRILL LANE ROSWELL, NM PH. (575) The health insurance information I have given today or at prior visits is up to date, complete, and insurances listed are current. I have no other insurances (including secondary or supplemental) that are not listed. Signed: Date:

6 INSURANCE NOTIFICATION: AS A COURTESY TO OUR PATIENTS WE WILL FILE YOUR INSURANCE FOR YOU. ANY AMOUNT NOT COVERED BY YOUR INSURANCE WILL BE DUE AND PAYABLE BY YOU, THE PATIENT. WE DO NOT HAVE ANY CONTROL OVER THE DEDUCTIBLE AMOUNTS, YOUR CO-PAY, OR WHATEVER YOUR INSURANCE APPLIES TO PATIENT RESPONSIBILITY. IF YOU HAVE QUESTIONS REGARDING WHAT INSURANCE HAS PAID OR DOES NOT PAY, PLEASE CONTACT YOUR INSURANCE CARRIER DIRECTLY. PATIENT SIGNATURE DATE COPY TO PATIENT- YOUR INITIALS

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