Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible.
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1 PAUL L. TREGER, M.D. RANDALL CONRAD, O.D. GLENN B. COOK, M.D., PhD TARA BROWN, M.D PARKWAY DRIVE SUITE LA MESA, CA FAX Dear Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible. Enclosed is your patient information sheet and medical history questionnaire. Please complete then and bring them with you on the date of your appointment. Please also bring with you a list of current medications, your health insurance card(s) and your glasses. If you should need to reschedule your appointment for any reason, please give us at least 24 hours notice. We look forward to serving you. Paul L. Treger, MD Glenn B. Cook, Md, PhD Randall Conrad, OD Tara Brown, MD
2 PAUL TREGER, M.D. RANDALL CONRAD, O.D. GLENN B. COOK, M.D., PhD. TARA BROWN, M.D. PLEASE REVIEW FOR ACCURACY AND COMPLETE WHERE APPROPRIATE PATIENT INFORMATION Name: Date of Birth: Address One: Social Security #: Address Two: Sex: F City: Usual Provider: GLENN COOK State: Zip: Employer: Home Phone#: Emergency Contact: Work Phone#: Emergency Phone#: Cell Phone#: Emergency Relationship: GUARANTOR INFORMATION Name: Date of Birth: Address One: Social Security#: Address Two: City: Employer: State: Zip Employer Address: Home Phone#: Employer City: Work Phone#: Employer State: Zip: Cell Phone#: INSURANCE INFORMATION Primary Insurance: Secondary Insurance: Certificate#: Certificate#: Group Number: Group Number: Group Name: Group Name: Copay: Copay: Subscriber Name: Subscriber Name: Authorization To Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to myself or to my Provider, La Mesa Eye & Paul Treger when he accepts assignment. Authorization To Release Medical Information. I hereby authorize my Provider, La Mesa Eye & Paul Treger to release any information necessary for my course of treatment. Signed (patient or parent if minor) Date
3 PAUL L. TREGER, M.D., F.A.C.S GLENN B. COOK, MD, PhD Medical History Form TODAYS DATE: PATIENT NAME FAMILY (PRIMARY) PHYSICIAN PHONE #( ) DO YOU HAVE ANY CURRENT MEDICAL PROBLEMS? PLEASE EXPLAIN CURRENT MEDICATIONS CURRENT EYE MEDICATIONS ALLERGIES YES NO PLEASE LIST MEDICAL SYSTEM REVIEW DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING: ( ) HIGH BLOOD PRESSURE ( ) CANCER OF ANY KIND ( ) DIABETES ( ) KIDNEY DISORDER ( ) BREATHING PROBLEMS ( ) THYROID DISEASE ( ) MIGRAINE HEADACHES ( ) STROKE ( ) HEART PROBLEMS ( ) SKIN DISORDER ( ) ANEMIA ( ) INTESTINAL DISORDER
4 PRIOR SURGERIES (INCLUDING EYE SURGERY) FAMILY HISTORY: FAMILY MEMBER: ( ) DIABETES ( ) HEART DISEASE ( ) HIGH BLOOD PRESSURE ( ) CANCER ( ) CATARACTS ( ) GLAUCOMA ( ) RETINAL DISEASE ( ) BLINDNESS SOCIAL HISTORY ( ) SMOKER PACKS PER DAY ( ) ALCOHOL USE AMOUNT PER DAY OCCUPATION EYE HISTORY: ( ) CONTACT LENSES IF YES WHAT TYPE? PREVIOUS EYE SURGERY: (PLEASE PROVIDE DATES) CATARACT R L LASER R L WHAT TYPE GLAUCOMA R L OTHER R L WHAT TYPE
5 EYE SYSTEM REVIEW: DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING PROBLEMS: ( ) COMPLETE OR PARTIAL LOSS OF VISION ( ) CATARACTS ( ) GLAUCOMA ( ) MACULAR DEGENERATION ( ) EYE DISEASE FROM DIABETES ( ) IRITIS OR INFLAMMATION INSIDE THE EYE ( ) DRY EYES ( ) EYELID INFECTIONS (BLEPHARITIS) ( ) LAZY (AMBLYOPIC) EYE ( ) CROSSED OR DEVIATED EYES ( ) DOUBLE VISION ( ) GROWTHS ON EYELIDS OR EYES ( ) EYE INJURY ( ) CONSTANT TEARING OF EYE(S) WHAT IS THE PURPOSE OF TODAY S EXAM?
6 PAUL L. TREGER, M.D. Tara L. Brown, M.D. GLENN B. COOK, M.D. Randall Conrad, O.D. TO OUR PATIENTS Refraction The portion of an eye exam known as a Refraction is not covered by most insurance companies (including Medicare). This part of the examination is done to determine your current need for glasses. The charge for the Refraction is $ If you do not wish this optional portion of the examination to be performed, please inform the technician at the beginning of the exam. If you wish to have this portion of the exam completed, and it is known that your insurance will not cover it, you will be asked to pay the $35.00 charge upon completion of your examination. No Show/ Canceled Appointment Policy If you fail to give our office 24 hour notice of cancellation of your appointment we reserve the right to charge you $25.00 for your appointment time. Returned Check Fee $25.00 Service charge Collection Services $50.00 Administration Fee will be added to the account Form Fee $10.00 Administration Fee for forms required to be completed by Physician Insurance Patients (PPO or HMO) You agree to assume full financial responsibility for all medical services provided to you in the event it is determined by the insurance carrier that you were ineligible for benefits at the time of service, did not provide correct insurance information, or the service was not covered. Signature Date Print Name
CORONADO EYE ASSOCIATES GLENN B. COOK, M.D., PhD 801 ORANGE AVENUE, STE. 204 - CORONADO, CA 92118 619.437-4406 FAX 619.522-7983
Dear Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible. Enclosed is your patient information sheet and medical history questionnaire. Please
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HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
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
Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.
Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
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
FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
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
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:
Welcome to Atlanta Southeast Center for Epilepsy & Neurodevelopment, PC
Welcome to Atlanta Southeast Center for Epilepsy & Neurodevelopment, PC We are looking forward to meeting you and your child! To help you prepare for your visit, please use the checklist below of items
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Name: Date: Address: City/State: County: Zipcode: Home Phone: Work Phone: Cell Phone: E-MAIL ADDRESS: Date of Birth: Male Female Marital Status: Single Married Separated Divorced
Marketing Samples Medical Optometry
Marketing Samples Medical Optometry Intended Use The purpose of this marketing sample packet is to provide examples of the ways your practice can implement text for newsletters, emails or letters, on-hold
Referrals It is your responsibility to bring your referral if required. Failure to do so may result in cancellation of your appointment.
Welcome to Capital Endocrinology! We are happy to have you as a patient in our practice. Please take note of the following policies. Following these policies will help in making your visit as efficient
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
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone: