State_ PLEASE GIVE ALL INSURANCE C TO OFFICE MANAGER FOR COPYING. State--=.--Zip. Briefly, why are you here today?.
|
|
|
- Rachel Richard
- 8 years ago
- Views:
Transcription
1 PATIENT INFORMATI0N: This section refers to the patient onlv. Name Address Home Phone ( City State_ Zip Northem Address (if applicable) Nonhern Phone (.City State--=.--Zip Age Date of Birth Sex Marital Status: Address SS# Occupation: (lf you are currently retired, please list former occupation). Physician PLEASE GIVE ALL INSURANCE C TO OFFICE MANAGER FOR COPYING Briefly, why are you here today?. Have you ever been exposed to loud noise? How did you hear about us? Do you or have you experienced any of the following conditions? Family History of Deafness Repeated ear infections or ear wax problems. Ear Surgery. TinnituslEar Ringing Sinus Disease Dizziness/Vertigo Headaches Ear pain/drainage Heart Disease Diabetes Hypertension Elevated Cholesterol Visual Impairment Please list all prescription rnedications (or provide us with a written list). Acknowledgement: I assume full responsibility for the payment of services rendered to'me and agree to pay in full for them at the time of delivery. I authorize Audiology Doctors of Florida, Corp. to release any medical information to my primary physician or to my insurance company, in order to process existing insurance claims. I understand I am responsible for any and all costs incurred by my failure to remit for any services rendered. I understand that even though Audiology Doctors of Florida, Corp. accepts assignment for most plans and may assist me in submitting claims to my insurance company, that I am responsible for any and all payments for services rendered, including all insurance co-payments and deductibles. I acknowledge, by my signature that I understand that the Audiology Doctors of Florida, Corp. does accept Medicare Assignment and that I say, by my signature, that I understand what this means. As required by law, Audiology Doctors of Florida, Co.p. will submit your Medicare fbr you. Signature Date
2 ?K'T'.'6*PLEASE COMPLETE FOR HEARING PROBLEMS ONLY***** 1. What is your hearing aid experience? tr I have a hearing device and use it regularly on the right ear _ left ear. tr I have a hearing device, but don't use it, or use it only -- occasionally. fl I tried a hearing device, but returned it for a refund. A I have inquired about hearing devices at another office(s), but did not purchase at that tirne. tr I have never used a hearing device. 2. Please rank the following items on a scale of I to 4 in terms of importance to you when purchasing a hearing device. (l : Most Important 2 : Important 3 : Somewhat Important 4:Least Important). Please use each number only once. _ Sound Quality & Clarity _ Durability/Reliability _ Cost _ Appearance 3. What motivated you to come in today? 4. On a scale of 1-10, where do you feel that you are (psychologically, emotionally, financially, etc.) regarding doing something about your hearing loss? (Please circle one) notmotivated I l0 verymotivated 5. When was your hearing last tested? 6. Does your Hearing Seem to be getting worse?. 7. Is one ear better than the other? Listening Situation How well do you hear in this situation? How often are you in this situation? Poor Fair Good Often Sometimes Rarely Television r-l tl n L] u il Music n I] il tl u! Restaurants n! tr I:] u t.i Church u I fl!! ll Meetings/Lectures rl tj u u t_l! Work Place u I u tl tr t.l Telephone Conversation n L] u n tr tr Car T tr il i-l! u Large Social Gathering n u u u L] I Quiet Room (l to 2 people) tr! u! tr! Page 2 e/20/2072
3 STEVEN D. SEDERHOLM, Au.D. Doctor of Audiology Characteristics of Amplification Tool (COAT) Name: Date: Audiologist: Our goal is to maximize your ability to hear so that you can more easily communicate with others. In order to reach this goal, it is important that we understand your communication needs, your personal preferences, and your expectations. By having a better understanding ofyour needs, we can use our expertise to recommend the hearing aids that are most appropriate for you. By working together we will find the best solution for you. Please complete the following questions. Be as honest as possible. Be as precise as possible. Thank you. 1. Please list the top three situations where you would most like to hear better. Be as specific as possible. 2. How important is it for you to hear better? Mark an X on the line. Not Very Important Very Important J. How motivated are you to wear and use hearing aids? Mark an X on the Not Very Motivated line. Vay Motivated 4. How well do you think hearing aids will improve your hearing? Mark an I expect them to: Not be helpful at all X on the line. Greatly improve my hearing 5. What is your most important consideration regarding hearing aids? Rank order the following factors with 1 as the most important and 4 as the least important. Place an X on the line if the item has no importance to you at all. Hearing aid size and the ability of others not to see the hearing aids Improved ability to hear and understand speech Improved ability to understand speech in noisy situations (e.g., restaurants, parties) Cost of the hearing aids
4 COAT Page Do you prefer hearing aids that: (check one) are totally automatic so that you do not have to make any adjustments to them. allow you to adjust the volume and change the listening programs as you see fit. no preference 7. Look at the pictures of the hearing aids. Please place an X on the picture or pictures of the style you would NOT be willing to use. Your audiologist will discuss with you if your choices are appropriate for you - given your hearing loss and physical shape ofyour ear. tl tl BTE Full Slieil Carrill Mini BTE Flalf Sheli: Low pr-ofile E LIL- 8. How confident do you feel that you will be successful in using hearing aids. Not Very Confident Very Confident 9. There is a wide range in hearing aid prices. The cost of hearing aids depends on a variety of factors including the sophistication of the circuitry (for example, higher level technology is more expensive than the more basic hearing aids) and sizelstyle (for example, the CIC hearing aids are more expensive than the BTE instruments). The price ranges listed below are for lwo hearing aids. Please check the cost category that represents the maximum amount you are willing to spend. Please understand that you are not locked into that price range. It is just very helpful for us to know your budget so that we can provide you with the most appropriate hearing aids. Basic digital hearing aids: Cost is between $2900 to $3500 Basic Plus hearing aids: Cost is between $3500 to $3900 Mid-level digital hearing aids: Cost is between $3900 to $5500 Premium digital hearing aids: Cost is between to $7500 Thank you for answering the questions. Your responses will assist us in providing you with the best hearing healthcare.
5 9TEVEN D. SEDERHOTM, Au.D. - Doctor af Aadiology Felbzv, Atnericat Acadeny of Attdiology Certifudby the Ameiut Board of Aucliology 11i35 5. logroad, fiz Boynton Beach, Florida (56il Fdx (55D 73* BurnsRoad, t304 Palm Beach Gdrclerla, Eloncla 334L0 $6U Fax (55'L) 691-A%0 PRIVAqY PRACTICES ACKNOWLEDGMENT ACKI{OWLED GMENT F'ORNI I have received the Notice of Privacy Practices and I have been provided an opportudty to review it. NAME: (PLEASE PRrNT) BIRTII I}ATEI SIGNATURE: DATE: I authofiae the following individual to obtain information and/or copies of my records in my absence: Name Relationship,
Patient Information. Medical History. Audiologic History
Greenville, SC 29615 Patient Information Name Date of Birth Age Gender Male Female Employment Full Time Part Time Retired Referring Physician and/or PCP Send report to your physician? Yes No What is your
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
ADULT CASE HISTORY FORM: AUDIOLOGY SERVICES
2092 Gaither Rd., Suite 100 Rockville, Maryland 20850 301.424.5200 Fax 301.424.8063 TTY 301.424.5203 www.ttlc.org ADULT CASE HISTORY FORM: AUDIOLOGY SERVICES Patient Information Name Date of Birth Sex
Freedom Hearing Center LLC
14090 H.G. Trueman Road, Suite 1400 Solomons, MD 20688 410-610- 2246 Rebecca L Jahed, AuD, FAAA Welcome to Freedom Hearing Center. My name is Dr. Rebecca L. Jahed and I am the President of this private
Occupational Noise Hearing Loss
Halifax Office Occupational ise Hearing Loss Please answer all questions on the following work place hearing loss and work history form. Complete information is necessary to properly adjudicate your claim
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?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
ADULT CASE HISTORY FORM (AUDIOLOGY)
UGA SPEECH AND HEARING CLINIC The University of Georgia Department of Communication Sciences and Special Education 706.542.4598 (office) 706.542.4574 (fax) ADULT CASE HISTORY FORM (AUDIOLOGY) Please complete
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
Byron's Hudson Valley Hearing Aid Centers Kingston/Lake Katrine 845-336-0108 Poughkeepsie 845-485-0168 Your hearing Journey
Your hearing Journey Don't miss out on the joys of life, your hearing is our concern. Trust our experts to enhance your quality of life. Ask Yourself: Do you have difficulty following a conversation in
P.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
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
------------- ------------- -----
PATIENT INFORMATION DATE: ----- Home Phone: ( ) Cell Phone: ( ) Last Name: First: Middle In. Sex: MIF ------------- ------------- ----- Age: Birth : I I SSN :(required, unless under 18): 1 1 Mailing Address:
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
Purchasing Hearing Aids What You Need to Know
Purchasing Hearing Aids What You Need to Know Thank you for interest in. Contained in this package is some valuable information to help you understand our company and to make an informed decision about
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
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
19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405
19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405 Welcome to our practice. We are happy that you selected us as your eye care provider and appreciate the opportunity
FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA
PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING
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
IMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11
PATIENT REGISTRATION 3.11 Last Name: First Name: MI: Local Address: City: State: Zip Code: DOB: Sex: Marital Status: Race: SSN [Required for reporting to Agency for Health Care Administration]: Were you
COSTS IN HEARING HEALTHCARE
COSTS IN HEARING HEALTHCARE Gail Linn, Au.D. Potomac Audiology Rockville, MD THE AUDIOLOGIST AND HEARING AID DISPENSER What is involved in dispensing a hearing aid? 1. Hearing Test to Determine Needs (1
THE EYE INSTITUTE. Dear Patient:
THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0464 Eye Institute North, LLC 5677 Berkshire Valley Rd. Oak Ridge, NJ 07438 p. 973-208-0600
Wow Your Patients. Quick and Effective Hearing Aid Demonstration
Wow Your Patients Quick and Effective Hearing Aid Demonstration Barbara J. Madden, Au.D. Doctor of Audiology Director of Audiology at Riddle Hospital/Main Line Health System in Media, Pennsylvania, USA
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Date Patient s Name Last First Initial Street Address City State Zip Code Phone No. Date of Birth Age Sex Married/Single Family Doctor Patient s Social Security No. - - Referring
Midha Medical Clinic REGISTRATION FORM
Midha Medical Clinic REGISTRATION FORM Today s / / (PLEASE PRINT NEATLY) PATIENT INFORMATION Last Name: First Name: Middle Initial: IS THIS YOUR LEGAL NAME? YES NO IF NOT, WHAT IS YOUR LEGAL NAME DATE
Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 info@benjamineye.com www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH
PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP E-MAIL HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS:
OUTPATIENT REHABILITATION CENTER
OUTPATIENT REHABILITATION CENTER 2131 K STREET NW, SUITE 620 WASHINGTON, DC 20037 OFFICE #: 202-715-5655 FAX #: 202-715-5664 Welcome to the George Washington University Hospital Outpatient Rehabilitation
Wisconsin Department of Health & Family Services Division of Disability and Elder Services Bureau of Aging & Long Term Care Resources
Waiver Wise Technical Assistance for the Community Options Program Waiver COP-W Wisconsin Department of Health & Family Services Division of Disability and Elder Services Bureau of Aging & Long Term Care
Patient Demographic Sheet
Patient Demographic Sheet Patient Name: Date of Birth: Address: City, State, Zip Code: Home Phone: Cell Phone: Work Phone: E-Mail: Sex: Male Female Marital Status: Married Single Other Occupation: Employer:
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
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:
Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.
Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)
The Top 5 Things You Should Know Before Buying Hearing Aids
S p e c i a l R e p o r t The Top 5 Things You Should Know Before Buying Hearing Aids Dr. Mary Anne Larkin, Au. D. Board Certified Doctor of Audiology Advanced Hearing Care The Top 5 Things You Should
Your Guide to Better Hearing
Your Guide to Better Hearing DID YOU KNOW? Did you kw that one in every ten Americans has hearing loss? That s 30 million people in this country alone! And the figures climb to one in three for people
PATIENT INTAKE INFORMATION
PATIENT INTAKE INFORMATION Patient Intake and Worker Compensation / Insurance Information Please have insurance card(s) available for copying Family Physician: Please fill in ALL blanks unless specified
Welcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
Westoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com Thank you for selecting Timberline to be a part of your rehabilitation. Below we have condensed
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
LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527 Patient Information Name First Middle Last Address City State Zip Phone Other Contact Email Social Security # DOB
Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip
Klein & Associates, M.D., P.A. Registration Form Patient s Last Name First MI Social Security # Date of Birth Age Sex M F Family Referring Doctor Doctor Home Address Apt # City State Zip Home Phone ( )
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
1 5 0 K E N N E D Y D R I V E S O U T H B U R L I N G T O N, V E R M O N T 0 5 4 0 3 8 0 2 4 4 8 9 3 7 0 8 0 2 4 4 8 1 4 1 4 (F)
Worker s Compensation Intake Form : Name: DOB: Social Security Address: City ST Zip Home Phone: Alternate Phone: Occupation: Employer Name: Employer Contact: Do you see a primary care physician for your
Thank you for visiting www.premierhearing.com and downloading your Free Hearing Information Pack.
Dear Valued Patient, Thank you for visiting www.premierhearing.com and downloading your Free Hearing Information Pack. We know how much a hearing device can change someone s life but we also know how hard
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600
PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company
How To Get A Medical Checkup From A Doctor
Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number:
DEL MAR PHYSICAL THERAPY Patient Information
PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************
Georgia Lions Lighthouse Foundation Better vision. Better hearing. Better Georgia.
Georgia Lions Lighthouse Foundation Better vision. Better hearing. Better Georgia. Thank you for contacting the Georgia Lions Lighthouse Foundation Hearing Program for hearing aid assistance. The Lighthouse
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 ( )
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
MVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
Noise Induced Hearing Loss Awareness. help
Noise Induced Hearing Loss Awareness help Noise Induced Deafness Awareness: Contents Noise Induced Hearing Loss Awareness Contents What can cause hearing loss? What are the symptoms? What is hearing loss?
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
Motor Vehicle Accident - New Patient
Motor Vehicle Accident - New Patient Today's Date: Patient Name: Auto Insurance Company of Car You Were In: Phone: Insurance Agent: Phone Was A Police Report Made? Have You Informed Your Agent of Your
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
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE WELCOME TO OUR OFFICE Patient Information Insurance Information Today s Date Last First MI Street City State Zip Code Home Phone Work Phone Cell Phone Email Address How do you prefer
Presbycusis. What is presbycusis? What are the symptoms of presbycusis?
Presbycusis What is presbycusis? Presbycusis is the loss of hearing that gradually occurs in most individuals as they grow older. Hearing loss is a common disorder associated with aging. About 30-35 percent
Ty K. Swartzlander, M.D. 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL 33426 * Telephone (561) 413-2832 * Fax (888) 734-6559
1880 N. Congress Ave * Suite 320 * Boynton Beach, FL 33426 * Telephone (561 413-2832 * Fax (888 734-6559 "#$%$&'(#*+,%(-.-/+0,1%&$'.'$+2%,-345#%2','64..+0,74#'7%89-"-$'(:5&/%&+ Directions to the office
karrdds.com 1243 Joliet St. Dyer 219.322.7610 1881 Greenwood Dr. Crown Point 219.488.2410 kids@karrdds.com PATIENT INFORMATION GUARDIAN INFORMATION
1243 Joliet St. Dyer 219.322.7610 1881 Greenwood Dr. Crown Point 219.488.2410 kids@ PATIENT INFORMATION / / Email Patient Name (Last, First) Sex: M F Age Birthdate / / Home Phone Number ( ) Best phone
PATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
How to use your hearing aid. How to use your digital. easy read. hearing aid. Also available: How to use your analog hearing aid
How to use your digital easy read hearing aid Also available: How to use your analog hearing aid Designed and illustrated by CHANGE 2012 When you first get your hearing aid: Practise using the controls.
PATIENT REGISTRATION Chitranjan Ranawat Amar Ranawat Anil Ranawat
PATIENT REGISTRATION Chitranjan Ranawat Amar Ranawat Anil Ranawat Last Name First Name Address City State Zip Sex M F Date of Birth SS # - - Home Phone Work Cell Occupation presently working Yes NO Email
PACIFIC PHYSICAL THERAPY & SPORTS REHABILITATION HERMOSA BEACH
PACIFIC PHYSICAL THERAPY & SPORTS REHABILITATION HERMOSA BEACH PATIENT INFORMATION Patient Name: Address: Telephone: E-mail address: Birthdate: SS#: Employer: Occupation: Home Cell Work Gender: Male Female
PATIENT /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
How To Get A Physical Therapy At West Point Physical Therapy Center
Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA 93551 (661)265-0060 To our workers compensation patients: Cathedral City 68-845 Perez Rd., Ste. H6-H7 Cathedral City, Ca 92234 (760)328-0292 California
The Eye Care Center of New Jersey 108 Broughton Avenue Bloomfield, NJ 07003
The Eye Care Center of New Jersey 108 Broughton Avenue Bloomfield, NJ 07003 Dear Patient, Welcome to The Eye Care Center of New Jersey! It means a great deal to us that you have chosen us to serve as your
CONSENT FOR MEDICAL TREATMENT
CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern
Types of hearing aids There are a number of different types of hearing aids to choose from, although not all will necessarily be suitable for you.
What do hearing aids do? Hearing aids are designed to amplify sounds so that they are loud enough, but not uncomfortably loud. The amplification volume depends on the type and degree of hearing loss you
Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
Patient Information: In Case of Emergency: Physician: Insurance:
For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:
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
PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI
275 Collier Road NW, Suite 470 Atlanta, GA 30309 Tel: 404-351-1002 Fax: 404-350-8290 PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME
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
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
LAFAYETTE BONE AND JOINT CLINIC PATIENT INFORMATION
PLEASE PRINT LAFAYETTE BONE AND JOINT CLINIC PATIENT INFORMATION TO SEE: (circle one) Dr. Cobb Dr. Blanda Dr. Hodges Dr. Muldowny Dr. Stubbs Account# NAME OF PATIENT: Last First Middle ADDRESS: Number
(ensure you read and sign page 5),
Customer Services 9912-107 Street PO Box 2415 Edmonton, Alberta T5J 2S5 Tel: 780-498-3999 Fax: 1-800-661-1993 WCB website: www.wcb.ab.ca Please find enclosed a Hearing Information Questionnaire and Workers
Hearing Aids. What Is a Hearing Aid? How Common Is Hearing Loss and What Causes It? How Do We Hear?
Hearing Aids What Is a Hearing Aid? A hearing aid is an electronic, battery-operated device that amplifies and changes sound to allow for improved communication. Hearing aids receive sound through a microphone,
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete
Florida Eye Center Patient Registration Form (Please Print Clearly)
Florida Eye Center Patient Registration Form (Please Print Clearly) Personal Information Legal Name: Last First MI Suffix Nickname: Social Security: - - Drivers License # Date of Birth: / / Mailing Address:
TALLAHASSEE EYE CENTER
TALLAHASSEE EYE CENTER PATIENT INFORMATION Date: Name: Gender: M / F First MI Last Date of Birth: / / Address: City: State: ZIP: Phone Numbers: Home: Cellular: Work: E-Mail: SS#: - - What is the best way
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
Stonebridge Adult Medicine, P.A. Registration Form (Please Print)
Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female
REHAB XCEL, LLC. NEW PATIENT INFORMATION
REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S
How To Help With Your Hearing Loss In New Zealand
June 2010 Adults over 16 years Are you deaf or do you find it difficult to hear? If so, this booklet has information on some of the services available from different government organisations and other
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked
ASU Speech & Hearing Clinic Hearing Aid Services
ASU Speech & Hearing Clinic Hearing Aid Services Thank you for considering the ASU Speech & Hearing Clinic for your hearing healthcare needs. The purchase and fitting of hearing instruments is a very important
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
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:
Audiometric (Hearing) Screening September November 2013
Audiometric (Hearing) Screening September November 2013 Sample Report QLD Prepared by: Name of Technician Qualified Audiometric Technicians INTRODUCTION Australasian Safety Services provided on-site audiometric
Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print-
HEALTH HISTORY Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print- Date: 20 Date of Birth: Patient s name: First Middle Last Name Patient Prefers to
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:
AON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?
Physical Therapy Services Medical History Form
Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently
Fran, Medical Assistant Kim, Office Manager, Referral Coordinator, Billing Specialist
GFP GARDENS FAMILY PRACTICE Phone (561) 627-7433 Fax (561) 775-1055 Welcome To Gardens Family Practice! We are happy to have you join our family and would like to give you some general information regarding
PACIFIC PHYSICAL THERAPY 14650 Aviation Blvd., Suite 200 Manhattan Beach, CA 90250. Referring Doctor: PLEASE PRINT CLEARLY Email Address:
PACIFIC PHYSICAL THERAPY 14650 Aviation Blvd., Suite 200 Manhattan Beach, CA 90250 Date: Referring Doctor: PLEASE PRINT CLEARLY First Name: Last Name: Height: Address: City, St., Zip:_ Email Address: _