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- Amice Robinson
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1 CELL PHONE:
2 PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood pressure Heart attack/angina Congestive heart failure Stroke Lung disease (specify) Liver disease (specify) Please click if you have any of the following:` Blood clots Stomach ulcers Diabetes Cancer (specify) Asthma Kidney disease (specify) Other Hepatitis B Hepatitis C Tuberculosis HIV infection List All Previous Surgeries(hernia, heart, knee, etc) Date Family History Medical condition Type (if applicable) Relationship Age of onset Cancer (type) Y N Heart disease Y N Diabetes Y N Blood clots Y N Asthma Y N Gout Y N Rheumatologic Conditions Y N
3
4 PATIENT: (LAST NAME) (FIRST NAME) (M.I.) (NICKNAME) DATE OF BIRTH: AGE: SEX: Male Female HEIGHT: WEIGHT: BLOOD PRESSURE: / REASON FOR VISIT WERE YOU INJURED ON THE JOB? Yes No IF SO, PLEASE GIVE DATE of INJURY: Has this been reported to your employer? Yes No Other doctor(s) on case? Name of Industrial Carrier: ID/Case#: Case Manager: Phone: Ext: WHAT WILL THE DOCTOR/PT BE EXAMINING? Right Left IF ACCIDENT OR INJURY, GIVE DATE OF INJURY: BRIEF DESCRIPTION: LIST YOUR SPORTS AND FITNESS ACTIVITIES: REVIEW OF SYMPTOMS Please click Yes or No for any current problems related to the areas listed below. 1. CONSTITUTIONAL 5. CARDIOVASCULAR Y N Weight Change Y N Chest pain/angina Y N Fever Y N Heart murmur Y N Sweats Y N Leg swelling Y N Fatigue 6. GASTROINTESTINAL 2. EYES Y N Acid Reflux Y N Blurred Vision Y N Heartburn Y N Blood in stools 3. EARS, NOSE, THROAT Y N Diarrhea Y N Loss of Hearing Y N Constipation Y N Dizziness Y N Nose bleeding 7. ENDOCRINE SYSTEM Y N Gum bleeding Y N Frequent Urination Y N Sweats 4. Y N Heat or cold intolerance Y 8. BREAST/GENITAL Y N Y N Menopause Y N Masses Y N Discharge None of the above symptoms 9. URINARY SYSTEM Y N Pain with urination Y N Incontinence Y N Trouble urinating Y N Blood in urine 10. SKIN Y N Rashes 11. NEUROLOGIC Y N Numbness Y N Nerve Pain Y N Weakness 12. PSYCHIATRIC Y N Depression Y N Anxiety 13. MUSCULOSKELETAL Y N Chronic joint pain Y N Chronic swelling Please indicate if you use the following substances: Tobacco Current everyday smoker Current some day smoker Former smoker Never smoker Heavy tobacco smoker Light tobacco smoker Smoker current status unknown Unknown if ever smoked Alcohol Never Rarely Social Daily Other: Recreational Drugs Never Rarely Social Daily Other: Please provide LAST DATE for the following: 1. Mammogram: 5. Bone Mineral Density Test: 2. Colorectal Cancer Screening: 6. Spirometry: 3. Glaucoma Screening: 7. Influenza Vaccine: 4. Cervical Cancer Screening: 8. Annual Dental Visit: DATE: SIGNATURE: Relationship to Patient
5 PATIENT: The! information! presented! here! enables! you! to! consent! for! needed! medical! services,!as!well!as!for!the!release!of!information!from!your!medical!records!for! medical!and!administrative!purposes.! Consent'for'Treatment:!!I!am!presenting!myself!for!outpatient!care!at!Idaho!Sports!Medicine!Institute,!PA!and!I! voluntarily! consent! to! the! rendering! of! such! care,! including! diagnostic! procedures! and! medical! treatment! by! authorized!agents!and!employees!of!idaho!sports!medicine!institute,!pa!and!by!medical!staff!or!their!designees!as! in!their!professional!judgment!may!be!deemed!necessary.!!i!acknowledge!that!no!guarantees!have!been!made!to! me!as!to!the!result!of!examination!or!treatment!in!this!clinic.!!!initial!' HIPAA' Acknowledgement:!! I! hereby! acknowledge! that! I! have! received! a! copy! of! the! Idaho! Sports! Medicine! Institute,!PA!Notice!of!Privacy!Practices!on!this!date!or!on!a!previous!date.!!Initial!' Release'of'Information:!!I!authorize!ISMI!to!release!any!information!from!my!medical!record,!including!information! about!my!treatment!to!a!third!party!payer!or!a!designated!review!agency!for!the!purpose!of!processing!my!claim.! Initial!' ' PAYMENT' AGREEMENT:!! All! services! rendered! are! charged! to! the! patient.!! We! will! file! your! claim! if! you! have! supplied!us!with!insurance!information!in!a!timely!manner.!cowpays,!deductible!or!percentage!amounts!are!due!at! the!time!of!service!unless!advance!arrangements!have!been!made!with!ismi.!!!monthly!statements!will!be!mailed!to! you! and! payment! is! expected! once! a! month.!! The! patient! is! responsible! for! all! fees,! regardless! of! insurance! coverage.!! Outstanding! accounts! 60! days! or! older! may! be! transferred! to! and! administrated! by! Account! Billing! Services! (ABS).!! ABS! will! set! up! a! payment! plan! with! you! and! charge! monthly! interest.!! If! litigation! must! be! instituted!to!collect!your!account!then!you!agree!to!pay!all!of!the!reasonable!attorney!fees!and!court!costs!incurred! in!collecting!the!amount!due.!!!initial!' ' MISSED'APPOINTMENTS:''Broken!appointments!or!late!notice!cancellations!are!a!significant!cost!to!the!practice.! Cancellations!are!requested!24!hours!prior!to!the!appointment!to!give!us!the!time!to!offer!the!time!slot!to!another! patient.!!we#reserve#the#right#to#charge#$50.00#for#missed#appointments.!!initial!!!! ASSIGNMENT'OF'BENEFITS!!(non;Medicare!patients!only)! I!hereby!authorize!payment!directly!to!Idaho!Sports!Medicine!Institute,!PA!of!all!healthcare!benefits,!not!to!exceed! charges,!to!which!i!would!otherwise!be!entitled!for!these!services.!i!agree!that!the!cumulative!payments!received! by!ismi!from!all!sources!shall!be!applied!to!pay!the!entire!charge!for!ismi s!medical!services!without!reduction!in! charges! whatsoever! for! plan! adjustments! in! order! that! ISMI! is! paid! in! full! for! such! services! if! and! when! the! undersigned!has!multiple!insurance!policies!or!coverages!for!the!medical!services!being!provided!by!ismi!and!the! applicable! insurance! policies! or! coverages! do! not! coordinate! the! payment! of! benefits! for! such! services.!! I! understand!that!i!am!responsible!for!any!and!all!balances!owing.! Date''''''''''''''''''''''''''' '''''''''Patient'or'Responsible'Party'Signature'' ' MEDICARE'PATIENT S'ASSIGNMENT'AUTHORIZATION!!(for!Medicare!insured!patients!only)! I!request!that!payment!of!authorized!Medicare!benefits!be!made!on!my!behalf!to!Idaho!Sports!Medicine!Institute,! PA!for!any!services!furnished!to!me!by!their!providers.!!I!authorize!any!holder!of!medical!information!about!me!to! be!released!to!the!centers!for!medicare!and!medicaid!services!and!its!agents!to!determine!these!benefits!or!the! benefits!payable!for!related!services.!!this!authorization!is!in!effect!until!i!choose!to!revoke!it.! Date''''''''''''''''''''''''''' '''''''''Patient'or'Responsible'Party'Signature'' ' I'CERTIFY'THAT'I'HAVE'READ'AND'UNDERSTAND'THIS'FORM'AND'DO'VOLUNTARILY'AGREE'TO'ITS'PROVISIONS.' Patient'Signature' Responsible'Person'' 'Date/Time' Relationship' (PATIENT!MUST!BE!18!YEARS!OR!OLDER!TO!SIGN.!!PARENT/GUARDIAN!SIGNATURE!REQUIRED!UNDER!18!YEARS!OF!AGE)! 1188!University!Dr.!!!Boise,!ID!!83706!!!! !!!Fax! !!!Toll!free!! !!!!!
6 HOSPITAL OWNERSHIP DISCLOSURE ( LASTNAME) (FIRSTNAME) (MI) (NICKNAME) As a patient of Idaho Sports Medicine Institute, your physician may order tests or schedule procedures that are performed at local hospitals. These include (but are not limited to) laboratory tests, x-rays, CT scans, MRIs, injections, and surgical procedures. Some of the physicians at Idaho Sports Medicine Institute are investors at Treasure Valley Hospital, which is one of the local hospitals that provide these services. Our physicians also practice at St. Alphonsus and St Luke s where they do not have an ownership interest. This form is to confirm that you understand, as a patient or Idaho Sports Medicine Institute, you have the right to choose the hospital where you would like to receive your services.
PATIENT INFORMATION INSURANCE INFORMATION
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460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca
Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
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Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex:
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Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.
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Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
Princeton and Rutgers Neurology, P.A. A Center Of Excellence
DEMOGRAPHICS Patient s Last Name: First Name: Address: City: State: Zip Code: Tel # (Cell): Tel # (Home): Tel # (Work) #: Preferred Method Of Contact: [] Cell Phone [] Home Phone [] Work Phone SS #: /
11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
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
PATIENT / VISIT INFORMATION PATIENT INFORMATION
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SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
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FAIRBANKS PHYSICAL THERAPY
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NEW PATIENT INFORMATION FORM
Woosik M. Chung, M.D. Timothy R. Kuklo, M.D., J.D. 303-762-DISC (3472) NEW PATIENT INFORMATION FORM Please print all information. By fully completing this form, you allow us to serve you quickly and efficiently.
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Westoaks Orthopaedic Associates
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Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology
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Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.
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Personal Injury Intake Form
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Interventional Spine Care New Patient History and Intake Form
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Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics
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BUPA Health Insurance (Thailand) Ltd. 104/9 Unit M02-03 The Avenue Chaengwattana Moo 1 Chaengwattana Tungsonghong Laksi Bangkok 10210
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3. Your copayment is expected at the time of visit. We accept cash, checks, Visa, MasterCard and Discover. We do not accept American Express.
We would like to welcome you as a patient and thank you for choosing Central Virginia Orthopaedics & Sports Medicine to provide your orthopaedic needs. It is our mission to provide you the highest level
Copayment Is Due At Time Of Visit. Self-pay (payment due at time of service)
REGISTRATION FORM Please present your insurance card and photo ID at time of check-in. Settlement of patient financial responsibility is expected at time of service. Copayment Is Due At Time Of Visit.
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