Sex: DMale Female. Last name: Insurance 1D#
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1 ORTHOPEDIC CARE AND SURGERY pg 1 of 8 Patient Demographic Information (Please print and fill out completely) Acct # Name: Address: DOB: Sex: DMale Female Home Phone:', Patient's Social Security #: Work Phone: Cell Phone: Primary Care Physician: Referring Doctor: First name: Pharmacy Name/Address: Last name: Phone Race: Caucasian Afiican American Native American Asian Hispanic Ethnicity: Hispanic/Latino Non-Hispanic Declined Language Insurance Information Primaiy Insurance Insurance ID #. Group # ; Effective date of insurance: Policy Holder Name(skip if same as patient):_ DOB Secondai7 Insurance: Insurance 1D# Groupr Policy Holder Name (skip if same as patient):^ Effective date of insurance: DOB Employer:_ Address: Phone: **Is this visit related to an automobile or work accident? DNo Yes If yes please indicate Auto DWork If yes please complete No fault/workers Comp form attached. Responsible Party Name (if same as patient, check and skip to next section) Date of Birth SSN: Address (Street) Home Phone (City) (State) Cell Phone (Zip) Work Phone Spouse/Significant Other Name_ Emergency Contact/HIPAA Contact_ Address Date of Birth Phone Relationship to Patient The information on all forms has been completed accurately to the best of my knowledge. I understand that it is my responsibility to notify the doctor's office of any changes in my infomiation. I also understand that this information will also be used for billing purposes and that I authorize the WNY KNEE AND ORTHOPEDIC SURGERY, PC to bill my insurance. Printed name of patient or guardian: (if patient under 18 years of age) Signature:
2 DOCTOR POLICY-PATIENT COPY WNY KNEE AND ORTHOPEDIC SURGERY, PC Acct# pg2 of 8 *YOU WILL NOT BE SEEN WITHOUT AN UPDATED REFERRAL IF ONE IS REQUIRED BY YOUR INSURANCE COMPANY. IF WE DO NOT HAVE A REFERRAL, YOUR APPOINTMENT MAY BE RESCHEDULED. IT IS YOUR RESPONSIBILITY TO CALL YOUR MEDICAL DOCTOR TO OBTAIN A REFERRAL. *CO-PAYMENTS AND DEDUCTIBLES ARE DUE AT THE TIME OF APPOINTMENT. WE ACCEPT CASH, CHECK, OR CHARGE (MASTER CARD, VISA, AND DISCOVER CARD) *IF YOU ARRIVE MORE THAN 15 MINUTES LATE, YOUR APPOINTMENT MAY BE RESCHEDULED TO THE NEXT AVAILABLE APPOINTMENT. *IF YOU NEED TO CANCEL YOUR APPOINTMENT, WE REQUIRE A 24-HOUR NOTICE OR YOU MAY BE CHARGED A $50.00 NO SHOW FEE. THERE IS A $ NO SHOW FEE FOR SURGERY. *IF YOU FAIL TO SHOW UP FOR 2 SCHEDULED OFFICE APPOINTMENTS WITHOUT CANCELLING, WE WILL BE UNABLE TO CONTINUE YOUR CARE. *ALL MEDICATION REFILLS CALLED IN AFTER 4PM ON THURSDAYS WILL BE FILLED THE FOLLOWING MONDAY. PLEASE PLAN ACCORDINGLY. *IF YOU ARE WAITING FOR A RETURN CALL FROM A PHYSICIAN, THIS WILL BE HANDLED AS QUICKLY AS POSSIBLE. NON-EMERGENT CALLS WILL BE RETURNED AFTER OFFICE HOURS IN MOST CASES. ROUTINE CALLS SHOULD BE MADE DURING BUSINESS HOURS. *OUR OFFICE IS OPEN MONDAY THRU FRIDAY SAM TO 4PM. CALLS MADE AFTER HOURS OR ON WEEKENDS ARE FOR EMERGENCIES ONLY. IF YOU HAVE A CALL BLOCK ON YOUR PHONE, PLEASE TURN IT OFF SO OUR PROVIDERS ARE ABLE TO RETURN YOUR CALL. ALTHOUGH UNUSUAL WE APOLOGIZE FOR OUR PROLONGED WAIT TIMES, BUT WE OFTEN SEE A LARGE NUMBER OF UNSCHEDULED PATIENTS DUE TO EMERGENCIES. PATIENT FORMS THERE IS A $10.00 FEE FOR FORMS TO BE FILLED OUT. THE PAPERWORK WILL NOT BE COMPLETED UNTIL THE FEE IS RECEIVED. PLEASE DO NOT ASK THE PHYSICIAN TO FILL FORMS OUT DURING OFFICE VISITS. FORMS ARE DONE ON A FIRST COME FIRST SERVED BASIS AND WE REQUIRE 7 DAYS TO PROCESS PAPERWORK. FINANCIAL POLICY WE ARE COMMITTED TO PROVIDING YOU WITH THE BEST CARE AND IN RETURN EXPECT FULL AND PROMPT PAYMENT FOR OUR SERVICES. YOUR CLEAR UNDERSTANDING OF THE ABOVE POLICIES IS IMPORTANT TO OUR PROFESSIONAL RELATIONSHIP.
3 WNY KNEE AND ORTHOPEDIC SURGERY pg3 of 8 Keith Stube, MD Jeffrey Rassman, RPA-C Allison Morganti, RPA-C Michael Parentis, MD Matthew Mazurczak, RPA-C Breanne Finucane, RPA-C 180 Park Club Lane, Suite 225, Williamsville, NY 3712 Southwestern Boulevard, Orchard Park, NY HIPAA-Your Health Infomiation is Protected by Federal Law What Infomiation is Protected? -Infomiation your doctors and other health care providers put in your medical record. -Conversations your doctor has about your care or treatment with others. -Information about you in your health insurers computer system. -Billing information about you from your clinic/healthcare provider. -You decide if you want to give permission before your health information may be shared. -If you believe your health information isn't being protected, you can: File a complaint with your health care provider or health insurer File a complaint with the US Government -You can ask your provider or health insurer questions about your rights. Providers and health insurers are required to follow this law and must keep your information private by: -Teaching people who work for them how your information may and may not be shared. -Taking appropriate and reasonable steps to keep your health information secure. To make sure your information is protected in a way that does not interfere with your healthcare, you information can be used and shared: -For your treatment and care coordination. -To pay doctors and hospitals for your healthcare. -With family, friends or others you identify who are involved with your healthcare. For more information:
4 Name: DOB: Acct# WNY KNEE AND ORTHOPEDIC SURGERY, PC ORTHOPAEDIC CARE & SURGERY pg4 of 8 Acknowledgement of Receipt of Notice of Privacy Practices By my signature below, I hereby acknowledge receipt of the Notice of Privacy Practices: Signature: Date: Medical Information Release Form (HIPAA Release Form) Name: Date of Birth: / / Release of Information I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: Spouse Child(ren) Other Information is not to be released to anyone. This Release of Information will remain in effect until tenninated by me in writing..signed: Date: / / MICHAEL A. PARENTIS, M.D. Breanne Finucane, RPA-C Matthew Mazurczak, RPA-C NORTHTOWNS 180 PARK CLUB LANE, STE 225 WILLIAMSVILLE, NY (P) KEITH C. STUBE, M.D. Allison Morganti, RPA-C Jeffrey Rassman, RPA-C SOUTHTOWNS 3712 SOUTHWESTERN BLVD. ORCHARD PARK, NY (P)
5 Acct# WNY KNEE AND ORTHOPEDIC SURGERY, PC ORTHOPAEDIC CARE & SURGERY FINANCIAL POLICY & INSURANCE WAIVER pg5 of8 We are committed to providing you with the best care, and in return, expect full and prompt payment for our services. Your clear understanding of the following policies and your responsibility is important to our professional relationship: - Copayments are due at the time of service. - Our office requires a 24 hour notice when cancelling an appointment, otherwise a $50.00 fee may be charged to your account. - We participate in most insurance plans. However, insurance is primarily a contract between you and your carrier. We must _ comply with the rules and regulations of your policy. Therefore, any balance due, per your carriers notification, is your responsibility. Please be aware of your covered benefits. I UNDERSTAND THAT WNY KNEE AND ORTHOPEDIC SURGERY, PC MAY NOT ACCEPT MY INSURANCE AND THAT IT IS MY RESPONSIBILITY TO VERIFY WITH MY HEALTH INSURANCE WHETHER OR NOT THE KNEE CENTER OF WNY IS A PARTICIPATING PROVIDER. 1 HEREBY AGREE TO PAY THE FULL AMOUNT OF MY OFFICE VISIT/SURGERY AT THE TIME OF SERVICE IF THEY ARE A NON-PARTICIPATING PROVIDER. FOR YOUR CONVENIENCE, WE ACCEPT MASTER CARD, VISA AND DISCOVER CARD FOR PAYMENT OF ALL CHARGES. RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS I have reviewed & understand the above financial policy & agree with the stated terms. I also authorize direct payment of medical benefits to the WNY KNEE AND ORTHOPEDIC SURGERY, PC & the release of medical information necessary for treatment, payment & healthcare operations. SIGNED: DATED: PATIENT INSURANCE WAIVER It has been explained to me that the WNY KNEE AND ORTHOPEDIC SURGERY, PC may not participate with my health.insurance plan. I understand that it is my responsibility to verify with my health insurance whether or not WNY KNEE AND ORTHOPEDIC SURGERY, PC is a participating provider. I hereby agree to pay the full amount of my office visit/surgery at the time of service if they are a non-participating provider. I understand that any balance that has not be satisfied at the time of service will be due immediately upon receipt of my first statement. If payment is not received or other arrangements are not made, further collection activity will commence. SIGNED: MICHAEL A. PARENTIS, M.D, Breanne Finucane, RPA-C Matthew Mazurczak, RPA-C NORTHTOWNS 180 PARK CLUB LANE, STE 225 WILLIAMSVILLE, NY (P) DATED: KEITH C. STUBE, M.D. Allison Morganti, RPA-C Jeffrey Rassman, RPA-C SOUTHTOWNS 3712 SOUTHWESTERN BLVD. ORCHARD PARK, NY (P)
6 WNY KNEE AND ORTHOPEDIC SURGERY, PC MEDICAL HISTORY FORM pg 6 of 8 Name: Age: Date of Birth: Height^ Weight Acct# Date: Primary Care Physician Main Complaint: Referred by Left Right Wound care Physician (if applicable): Rheumatologist (if applicable): Infectious Disease doctor (if applicable): Location of Pain: Severity DO D5 D6? DIO (least) (most) What causes the pain? Pain Duration CuiTent Problem No Pain Started Today Started Yesterday For a While Pain Quality No Pain Burning Sharp Sore Stabbing Pain Severity 1 (none) (moderate) Days Wks Mos_ Yrs (severe) Pain Timing Continuous Intemiittent Occasional Worse at night u Worse worse w/acuvuy w/activity Aggravates your Pain Activity Bending Moving Alleviates your Pain Anti-inflammatoi7 Rest Heat Ice Associated symptoms: Catching Giving Out Popping Spasms Stiffness List any allergies you have to drugs, food or other items: no known drug allergy Past Medical Problems: Past Surgical History Operations Performed Year Hospital Doctor REVIEW OF SYSTEMS Gastrointestinal (GI) Abdominal Pain Diarrhea Nausea Vomiting Reflux Neurologic Blackouts Fainting Headaches Tingling Cardiovascular Chest Pain Fainting Leg Swelling Ankle Swelling Exercise Intolerance Respiratory Difficulty Breathing Cough Congestion Wheezing Musculosketal Muscle Cramps Stiffness Back Pain Joint Pain Joint Swelling Blood/Lymph Easy Bleeding Excess Bleeding Enlarged Lymph Easy Bruising Work Related? DYes DNo Lawsuit? QYes DNo Attorney Name: Occupation: List prior Job if retired Marital Status Single Married Widowed Divorced # of children Do you smoke? DYes DNo Packs per day_ #years smoked if quit,when_ Do you drink alcohol Yes No #Drinks per day
7 WNY KNEE AND ORTHOPEDIC SURGERY, PC MEDICATION LIST pg7of8 Medication List Name: Acct # Are you currently taking any medications? Yes No If yes, please list below: Name, Dosage How Often >Jame Dosage How Often
8 WNY KNEE AND ORTHOPEDIC SURGERY, PC FOOT & ANKLE.HIPS.KNEES.SHOULDERS SPECIALIZING IN SPORTS INJURIES & MEDICINE Pg8of8 KEITH C. STUBE, M.D. JEFFREY RASSMAN, RPA-C ALLISON MORGANTI, RPA-C MICHAEL A. PARENTIS, M.D. MATTHEW MAZURCZAK, RPA-C.BREANNE FINUCANE, RPA-C MEMO To: All Patients From: Providers of WNY Knee and Orthopedic Surgery, PC Re: Estimates on Deductibles and Procedures Due to recent changes in government and insurance policies, the providers of WNY Knee and Orthopedic Surgery, PC are working to be proactive and give patients estimates for upcoming procedures and visits when they have deductibles and changes in co-payments. When procedures are considered elective, we will be asking for payment up front. Our staff is working diligently to get you this information, but as you are aware, deductibles update on a daily basis. Our staff will inform you prior to your surgery of the cost related to your procedure. VISCO injections and Durable Medical Equipment are also services that we render to our patients. These services can be costly when you still need to meet your deductible and/or coinsurance. Should you decide to move forward and receive the service, our policy is to collect your portion at the time of the visit. Our goal is to give you this information prior to the service being rendered. If you have any questions regarding your deductible or coinsurance, please call our billing department at option 9 and a billing representative will help you. '180 PARK CLUB LANE, SUITE SOUTHWESTERN BLVD. WILLIAMSVILLE, NY ORCHARD PARK, NY (P) (F) (P) FULL PHYSICAL THERAPY UNIT AT BOTH LOCATIONS URGENT CARE AT OUR ORCHARD PARK LOCATION
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Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
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PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET. Last First Middle Name: Name: Initial: Male: Address: City: State: Zip:
CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET Last First Middle Initial: Male: Is this your legal name? Female: Yes / no If not, what is your legal name: Address: City: State: Zip:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)
Orthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT
In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT 1) PATIENT REGISTRATION ACCT #: DR.: APPT. DATE: FIRST NAME MIDDLE LAST
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
Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Electronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
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:
OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)
OFFICE POLICIES Thank you for choosing Spencer Dermatology and Skin Surgery Center for your health care needs. We recognize that you have a choice in health care providers and we appreciate the trust that
317 N. EI Camino Real, Suite 405 Encinitas, CA 92024 (760) 994-2663. Dear Patient:
317 N. EI Camino Real, Suite 405 Encinitas, CA 92024 (760) 994-2663 Dear Patient: We are very happy to welcome you to Orthopedic Surgery San Diego. We appreciate the opportunity to take care of you and
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
Agnes Ju Chang, M.D., F.A.A.D.
Agnes Ju Chang, M.D., F.A.A.D. Dear Valued Patient: Thank you for choosing Integrated Dermatology of K Street, the office of board certified dermatologists, Dr. Agnes Ju Chang, Dr. David A. Lee, Allison
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.
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
PATIENT DEMOGRAPHIC SHEET
Patient Information PATIENT DEMOGRAPHIC SHEET Last Name First Name MI of Birth Age Social Security Number Married Widowed Single Other: Marital Status Occupation/Retired Employer English Spanish Mail Phone
X Guarantor/Parent/Guardian Signature
Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency
CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork
New Patient Paperwork NAME OF PATIENT ( ) MALE ( ) FEMALE ADDRESS APT CITY STATE ZIP HOME PHONE # CELL PHONE # DATE OF BIRTH AGE SOCIAL SECURITY # MARITAL STATUS E-MAIL ADDERSS OCCUPATION EMPLOYER EMPLOYER
Worker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
PAST MEDICAL HISTORY REVIEW OF SYSTEMS
SOUTHEASTERN SPORTS MEDICINE Page 1 of 6 21 Turtle Creek Drive Asheville, NC 28803 DATE PATIENT INFORMATION PATIENT NAME: Last First Middle ( ) Child ( ) Single ( ) Married ( ) Widow(er) ( ) Divorced Address
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
HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C.
Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C., to provide Care and Treatment to considered necessary
IS THIS PROBLEM WORK RELATED?
PATIENT NAME: (Last) (First) (Middle) Female Male Birth Date: Age: Social Security No: Single Married Widowed Divorced Mailing Address: (City) (State) (Zip) ok to leave a message Yes No Preferred Phone:
Patient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto
For Office Use Updated By (Initial Here): Mailing Address: Patient Information City, State & Zip: Primary Home Cell Permission to Leave Messages: Yes No Secondary Home Cell Permission to Leave Messages:
Orthopedic Patient Information
Orthopedic Patient Information Please complete the following questionnaire. It is designed to assist our providers with your care and better understand your medical information. Please answer every section.
Hand & Orthopedic Physical Therapy Associates, P.C.
Patient Name: Hand & Orthopedic Physical Therapy Associates, P.C. Date of Birth: ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) NOTE: If Medicare doesn t pay for items listed below, you may have to pay.
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME We are pleased you have chosen us for your physical therapy needs. Our office is committed to providing
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE DEMOGRAPHICS- To be completed by all patients Patient Name: Today s Date: / / Patient Address: _ City: State: Zip: Home Phone #: ( ) - Work #:
Nephrology Consultants of Georgia, P.C.
New Patient O (Check One) Established Patient O Name: (Last) _ (First) (MI) Address: City State Zip D.O.B. SSNO Email Address Ethnicity: O Hispanic or Latino O Not Hispanic or Latino O Patient Refused
Next Level Physical Therapy PC Patient Information
Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home
NORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
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 ( )
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
PATIENT INFORMATION INTAKE F O R M BESSMER CHIROPRACTIC P. C.
PATIENT INFORMATION INTAKE F O R M BESSMER CHIROPRACTIC P. C. Date today: _ PERSONAL INFORMATION Full Name: SS#: Address: City: State: Home Phone: Cell Phone: W o r k Phone: Email: Birthdate: Age: Sex:
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown)
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown) Patient Name: Date of Birth Mailing Address: City: State Zip: Apt/Ste/Unit/Bldg Primary Number:
Virginia South Psychiatric & Family Services
All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow
RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number:
RETINA CONSULTANTS OF HOUSTON 6560 FANNIN, SUITE 750, HOUSTON TX 77030 PATIENT INFORMATION Patient's Legal Name: Date of Today's Visit: Social Security # Date of Birth: Age: Sex: M F Martial Status: S
Policy Holder Name Relationship to Patient SSN DOB
Orthopedic Today s Date Patient s SSN# Legal First Name Last Name M.I. DOB Gender Parent/Guardian Name (for pediatrics) DOB Address City State Zip Home Phone Cell Phone Work Phone Email Have any members
PATIENT INFORMATION. Male Female ( ) / / Street Address / P.O. Box: City: State: Zip Code:
Today s : PATIENT INFORMATION Patient s Last Name: First: Middle: Mr. Miss Mrs. Ms. Dr. Home phone no.: Cell phone no.: Work phone no.: Birth : Marital Status (check one) Single Separated Married Widowed