Houston Rheumatology Center
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- Magdalene Parrish
- 8 years ago
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1 Houston Rheumatology Center Patient Information Patient Registration Form Today s Date: / / First Name MI Last Name - - Social Security # address / / Mailing Address Birth Date Age City State Zip Home Phone Marital Status: Single Married Widowed Separated Divorced ( ) - Cell Phone Employer Name and Address Work Phone Emergency Contact Relationship Phone Number Pharmacy Name Pharmacy Number Insurance Information Please provide copy of Insurance Card Insurance #1 (Primary) Phone Number Plan Name: Group ID#: Subscriber Name: Subscriber DOB: / / Specialist OV Copay$ Member ID#: Employer Group: Relationship to Patient: self spouse child other Effective Date: Insurance #2 (Secondary -if applicable) Phone Number Plan Name: Member ID#: Group ID#: Employer Group: Subscriber Name: Relationship to Patient: self spouse child other Subscriber DOB: / / Effective Date: Any additional information required to file claim:
2 Primary Care Doctor Information Doctor: Phone: ( ) - Address: Referral Information Referring Doctor: Phone: ( ) - Address: Third Party Liability MVA: State where accident took place: Other Liability: Work Comp other Date of Injury: PIP Carrier Name: Adjuster Name: Phone#: ( ) - Mailing Address: City Sate Zip: Claim Number: Date of Injury: Carrier Name: Adjuster Name: Phone#: ( ) - Mailing Address: City Sate Zip: Claim Number: Reason for today s visit: The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Sabeen Najam, MD, PA. I understand that I am financially responsible for any balances. I also authorize or Insurance Company to release any information required to process my claims. Patient/Guardian Signature Date Please note payment is due prior to services rendered unless prior arrangements have been made W. Baker Rd. Suite C 4102 Woodlawn Ave. Suite Bellaire Blvd. Suite 102 Baytown, TX Pasadena, TX Houston, TX (281) (713) (281)
3 Houston Rheumatology Center PatientHealthQuestionnaire Patient sname: DateofBirth: Sex:M/F PreviousPhysician (FacilityName) Listanyspecialistyouarecurrentlyseeing: Drug/FoodAllergies:Pleaselistanyandallallergiesyouhavepertainingtomedicationsandfood,alongwiththe reaction. CurrentMedications:Pleaselistanymedicationsthatyoutakeregularly.Includedosage,howoftenyoutakethem, andreason: Pleasecheckifyouoraspecificfamilymemberhaveorhadanyofthefollowing: (Ifpossible,indicatetheapproximateyearofyourmedicalproblem,andrelationshipofthefamilymember) Illness Self Family Relationship Illness Self Family Relationship Member Member Allergies HeartAttack Anemia HeartMurmur Arthritis HeartProblems Asthma Hepatitis BleedingTendency Hernia BirthDefects HighBloodPressure BreastProblems HighCholesterol Cancer/Tumor Kidney/Bladder Problems ChickenPox LiverProblems CongestiveHeart MentalProblems Failure(CHF) Depression PepticUlcer Diabetes RheumatoidFever Emphysema/COPD SexuallyTransmitted Diseases Epilepsy/Seizures SkinProblem Eye/Hearing Stomach/Bowel Problems Problems Gallstones Stroke/TIA Gout ThyroidProblems HayFever Tuberculosis Headaches 1
4 Houston Rheumatology Center Doyouuseorpreviouslyhaveused: Tobacco Alcohol Drugs Type How HowLong Whenended Often Explainallcheckedanswersandlistanyothermajororchronicillnessesnotlisted.Pleaseincludedatesofoccurrenceor onset. HospitalizationorSurgery:Includemajorinjuries,trauma,brokenbones,etc. Reason Date FORWOMEN: LastPAPsmear: LastMammogram: ExplainanyhistoryofabnormalPapsmear Explainanyhistoryofabnormalmammograms Haveyouused: Birthcontrolpills HormonalContraceptives(IUDorInjectable) Areyoucurrentlyusingbirthcontrol? Yes NoType: 2
5 AUTHORIZATIONTORELEASEHEALTHCAREINFORMATION Patient sname: DateofBirth: PreviousName: SocialSecurity#: Irequestandauthorize toreleasehealthcare informationofthepatientnamedto: HoustonRheumatologyCenter SabeenNajam,MD,PA 1610W.BakerRoadSuiteC Baytown,TX77521 (281) Fax(281) Thisrequestandauthorizationappliesto: Healthcareinformationrelatingtothefollowingtreatment,condition,ordates: Allhealthcareinformation Other: Definition:SexuallyTransmittedDisease(STD)asdefinedbylaw,RCW70.24etseq.,includesherpes,herpessimplex,humanpapillomavirus,wart,genitalwarts, condyioma,chlamydia,non specificurethritis,syphilis,vdrl,chancroid,lymphgranulomavenereuem,hiv(humanimmunodeficiencyvirus),aids(acquired ImmunodeficiencySyndrome),andgonorrhea. Yes No IauthorizethereleaseofmySTDresults,HIV/AIDStesting,whethernegativeorpositive,totheperson(s)listedabove.Iunderstandthatthe person(s)listedabovewillbenotifiedthatimustgivespecificwrittenpermissionbeforedisclosureofthesetestresultstoanyone. Yes No Iauthorizethereleaseofanyrecordsregardingdrug,alcohol,ormentalhealthtreatmentstotheperson(s)listedabove. PatientSignature: Datesigned: Thisauthorizationexpires.(Ifdatenotspecified,authorizationwillexpireinoneyear.)
6 Houston Rheumatology Center Practice limited to Rheumatology 9440BellaireBlvd.1610W.BakerRd4102WoodlawnAvenue Suite102SuiteCSuite200 Houston,TX77036Baytown,TX77521Pasadena,TX77504 Tel: Tel: Tel: Fax(AllLocations): Web: HIPAANoticeofPrivacyPractices THISNOTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBEUSEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION.PLEASE REVIEWITCAREFULLY. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or healthcare operations(tpo)andforotherpurposesthatarepermittedbylaw.italsodescribesyourrightstoaccessandcontrolyourprotectedhealthinformation. Protected HealthInformation''isinformationaboutyou,includingdemographicinformation,thatmayidentifyyouandthatrelatestoyourpast,presentorfuturephysicalor mentalhealthorconditionandrelatedhealthcareservices. UsesanddisclosuresofProtectedHealthInformation: Yourprotectedhealthinformationmaybeusedanddisclosedbyyourphysician,ourofficestaffandothersoutsideofourofficethatareinvolvedInyourcareand treatmentforthepurposeofprovidinghealthcareservicestoyou,topayyourhealthcarebills,tosupporttheoperationofthephysician'spractice,andanyotheruse asrequiredbylaw. Treatment:Wewilluseanddiscloseyourprotectedinformationtoprovide,coordinate,andmanageyourhealthcareandanyrelatedservices.Thisincludesthe coordinationormanagementofyourhealthcarewithathirdparty.forexample,wewoulddiscloseyourprotectedhealthinformation,asnecessarytoahomehealth agencythatprovidescaretoyou.forexample,yourprotectedhealthinformationmaybeprovidedtoaphysiciantowhomyouhavebeenreferredtoensurethatthe physicianhasthenecessaryinformationtodiagnoseortreatyou. Payment:Yourprotectedhealthinformationwillbeused,asneeded,toobtainpaymentforyourhealthcareservices.Forexample,obtainingapprovalforahospital staymayrequirethatyourrelevantprotectedhealthinformationbedisclosedtothehealthplantoobtainapprovalforthehospitalstay. HealthcareOperations:Wemayuseordisclose,asneeded,yourprotectedhealthinformationinorderstosupportthebusinessactivitiesofyourphysician'spractice. These activities include, but are not limited to, quality assessment activities, employee review activities, training medical students, licensing, and conducting or arranging for other business activities, For example, we may disclose your protected health information to medical students that see patients in our office. In addition,wemayuseasign insheetattheregistrationdeskwhereyouwillbeaskedtosignyournameandindicateyourphysician.wemayalsocallyoubynamein thewaitingroomwhenthephysicianisreadytoseeyou.wemayuseordiscloseyourprotectedhealthinformation,asnecessary,tocontactyoutoremindyouof yourappointment.wemayuseordiscloseyourprotectedhealthinformationinthefollowingsituationswithoutyourauthorization.thesesituationsinclude:as RequiredbyLaw,PublicHealthissuesasregardedbylaw,CommunicableDiseases,HealthOversight,AbuseNeglect,FoodandDrugAdministrationrequirements, LegalProceedings,LawEnforcement,Coroners,FuneralDirectors,andOrganDonation,Research,CriminalActivity,MilitaryActiveandNationalSecurity,Workers' Compensation,Inmates,RequiredusesandDisclosures,Underthelaw,wemustmakedisclosurestoyouandwhenrequiredbytheSecretaryofTheDepartmentof HealthandHumanServicestoinvestigateordetermineourcompliancewithrequirementsofSection OtherPermittedRequiredUsesandDisclosures:Willbemadeonlywithyourconsent,authorizationoropportunitytoobjectunlessrequiredbylaw.Youmayrevoke thisauthorization,atanytime,inwriting,excepttotheextentthatyourphysicianofthephysician'spracticehastakenanactioninrelianceontheuseordisclosure indicatedintheauthorization. You rerights:followingisastatementofyourrightswithrespecttoyourprotectedhealthinformation. YouHavetheRighttoInspectandCopyYourProtectedHealthInformation:Thismeansyoumayaskusnotdiscloseanypartofyourprotectedhealthinformation forthepurposeoftreatment,paymentorhealthcareoperations,youmayalsorequestthatanypartofyourprotectedhealthinformationnotbedisclosedtofamily membersorfriendswhomaybeinvolvedinyourcareorfornotificationpurposesasdescribedinthenoticeofprivacypractices.yourrequestmuststatethespecific restrictionrequestedandtowhomyouwanttherestrictiontoapply. Yourphysicianisnotrequiredtoagreetoarestrictionthatyoumayrequest.Ifthephysicianbelievesitisinyourbestinteresttopermituseanddisclosureofyour protectedhealthinformation,yourprotectedhealthinformationwillnotberestricted.youthenhavetherighttouseanotherhealthierprofessional. YouHavetheRighttoRequesttoReceiveConfidentialCommunicationsfromusbyAlternativemeansoratanAlternativelocation.YouHavetheRighttoObtaina PaperCopyofThisNoticeFromUs,UponRequestevenifyouhaveAgreedtoAcceptThisNoticeAlternatively,i.e.electronically. YouMayHavetheRighttoHaveYourPhysicianAmendYourProtectedHealthInformation:Ifwedenyyourrequestforamendment,youhavetherighttofilea statementofdisagreementwithusandwemaypreparearebuttaltoyourstatementandwillprovideyouwithacopyofanysuchrebuttal. YouHavetheRighttoReceiveanAccountingofCertainDisordersWehaveMade,ifany,ofYourProtectedHealthInformation.Wereservetherighttomakeany changestothisnoticeandwillinformyoubymailofanychanges.youthenhavetherighttoobjectorwithdrawasprovidedinthisnotice. Complaints:YoumaycomplaintousortotheSecretaryofHealthandHumanServicesifyoubelieveyourprivacyrightshavebeenviolatedbyus.Youmayfilea complaintbynotifyingourprivacycontactofyourcomplaint.wewillnotretaliateagainstyouforfilingacomplaint. Thisnoticewaspublishedandbecomeseffectiveon/orbeforeApril14,2003. Wearerequiredbylawtomaintaintheprivacyof,andprovideindividualswiththisnoticeofourlegaldutiesandprivacypracticeswithrespecttoprotectedhealth information.lfyouhaveanyobjectionstothisform,pleaseasktospeakwithourhippacomplianceofficerinpersonorbyphoneatourmainphonenumber. SignaturebelowisonlyanacknowledgementthatyouhavereceivedthisNoticeofPrivacyPractices. PrintName: Signature: Date:
7 Name:Date: PastMedicalHistory SocialHistory OAnemia OHeartattack Doyouconsumealcoholicbeverages OArthritis OStrokes OYes ONo OAsthma OHepatitis Doyousmoke?OYes ONo OBloodclots OHighBloodPressure IVDrugabuse OYes ONo OCancer/Tumor OHighCholesterol OCongestiveHeartFailure OKidneyProblems FamilyHistory ODepression OLiverProblems Hasanyoneinyourfamilyhadthe ODiabetes OPepticUlcer/Reflux followingsymptom? OEmphysema/COPD OSkinProblem OArthritis OEpilepsy/Seizures OStomach/BowelProblems OHypertension OEyeProblems OThyroidProblems OHeartDisease OGout OTuberculosis ODiabetes SurgicalHistory RightKneereplacementOYes ONo LeftKneereplacement OYes ONo Righthipreplacement OYes ONo Lefthipreplacement OYes ONo ThyroidremovalsurgeryOYes ONo ROS:Darkenthecircleforyesorno.Allquestionsmustbeanswered drymouth OYes ONo musclepain OYes ONo scalptenderness OYes ONo weakness OYes ONo jawclaudication OYes ONo anxiety OYes ONo alopecia OYes ONo depression OYes ONo headache OYes ONo rash OYes ONo soresinnose OYes ONo colorchangeinfingerwithcold OYes ONo soresinmouth OYes ONo tightness OYes ONo difficultyinswallowing OYes ONo dryskin OYes ONo snoring OYes ONo fatigue OYes ONo chestpain OYes ONo coldintolerance OYes ONo shortnessofbreath OYes ONo heatintolerance OYes ONo difficultyswallowing OYes ONo seizures OYes ONo nausea OYes ONo confusion OYes ONo vomiting OYes ONo blurringofvision OYes ONo abdominalpain OYes ONo dryeyes OYes ONo heartburn OYes ONo visualchanges OYes ONo jointswelling OYes ONo cough OYes ONo jointpain OYes ONo digitalulcer OYes ONo jointstiffness OYes ONo fever OYes ONo jointredness OYes ONo nightsweats OYes ONo weightloss OYes ONo
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
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Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
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Date: PATIENT NAME (Last, First M.I.): PATIENT INFORMATION (Please complete all sections) Office Location: DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
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PEDIATRIC MEDICAL HISTORY FORM
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DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single
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Tell Us About Your Child. Dental History. Medical History
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MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form Front Office Person calls in for a new patient appointment. o Never seen at SWAN o Previously Seen at SWAN The following
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New Patient Registration Form
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Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated
Patient Information Last Name First Name MI Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Race (circle): Black White Asian Other Ethnicity
Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
PATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:
Anthony N. Dardano, D.O., P.A., F.A.C.S. AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY Diplomate of the American Board of Plastic Surgery Diplomate of the American Board of Surgery 951 N.W. 13 th Street,
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834 Dear New Patient: Welcome to Associates in Pediatric and Adult Urology, PA, a
Luna Spine and Orthopaedic Surgery Mario E. Luna, MD
PATIENT INFORMATION NAME (Last, First, Middle Initial) PRIMARY ADDRESS PATIENT REGISTRATION FORM EMERGENCY CONTACT NAME (Relationship to Patient) CITY, STATE, ZIP CITY, STATE, ZIP PHONE ( ) HOME ( ) CELL
Advanced Solutions Pain Management
Joseph Ho, M.D. Sabrina Shue, M.D. Patient Information Name: M F Age: Last, First, Middle (Circle One) DOB: SSN: Single Married Divorced Separated Widowed Address: City: State: Zip: Home Phone: Cell: Work:
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )
Advantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
Orthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:
David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: INSURANCE INFORMATION Did you injure yourself at work or is this injury a
If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.
Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical
Name: Date of Birth: Social Security #: Home # Cell # Address: City: State: Zip: Emergency Contact #: Relationship:
California Back and Pain Specialists 14624 Sherman Way, Suite 309, Van Nuys, CA 91405 1172 Swallow Lane, Simi Valley, CA 93065 101 Hodencamp Road, Suite 103, Thousand Oaks, CA 91360 9201 Sunset Blvd, Suite
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions
18 HEALY DR. WINSTON SALEM, NC 710 PH. 6-768-50 FAX- 768-19 Scott W. Baker, MD Patient Instructions 1. Bring a list of all regular medications and dosages.. Bring your insurance card and all necessary
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax
Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments
PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:
PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE
Houston Primary Care REGISTRATION FORM (Please Print)
Houston Primary Care REGISTRATION FORM (Please Print) Today s date: Email: PATIENT INFORMATION Patient s First and last name: Middle Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep
Houston Healthcare Therapy Agreement
Houston Healthcare Therapy Agreement We will do our best to: Begin all sessions on time Explain your treatment program and progress to you Accommodate your schedule Be consistent with your therapist and
You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)
Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork.
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork. So we may eliminate any potential waiting time, please fax the completed forms
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949 Thank you for choosing Lanier Chiropractic and Rehabilitation! It is our desire
Grey Physical Therapy and Sports Medicine Center
Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First
Keweenaw Holistic Family Medicine Patient Registration Form
Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend
1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER
Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900
PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip
PATIENT REGISTRATION Date:
PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - -
Appointment Information Date: Time: Physician: Patient Information Name: First MI Last Street Address Apt. or Post Office Box City State Zip Telephone Primary: ( ) Home Work Cell Work: ( ) Cell: ( ) Date
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
How to Remove a Social History Smoke?
AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp
New Patient Information Form
PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?
WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone:
WORKERS COMPENSATION INFORMATION PATIENT INFORMATION Name: Birthdate: Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: Preferred Pharmacy: Tel
How did you hear about our office?
PATIENT INFORMATION Patient's name Preferred name Male Female If minor, responsible party name Mailing address City State Zip Social Security Number Birth date Home phone Work phone Cell phone Email Employer
Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470
PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone
PATIENT INFORMATION FILL OUT ALL ITEMS
PATIENT INFORMATION FILL OUT ALL ITEMS FAILURE TO COMPLETELY FILL OUT THIS FORM MAY RESULT IN YOU BEING BILLED IN FULL Patient Last Name: First: MI:. Address:. Date of Birth: Gender: M or F Marital Status:
RALEIGH NEUROSURGICAL CLINIC, INC.
Revised 09/26/14 PATIENT INFORMATION RALEIGH NEUROSURGICAL CLINIC, INC. Age: Sex: M F Date Last Name First Name Middle Initial Mailing Address City State Zip Social Security # Home Phone ( ) Cell Phone
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net
360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first appointment at our office on
LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS
The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com
1 Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com DEMOGRAPHICS & INSURANCE Patient Information Name: (First) (MI) (Last) SS#: DOB: Sex: Male Female Address: