HAROLD F. MOESSNER, M.D. JOSEPH T. BELLEAU, M.D. NAME: MALE FEMALE ADDRESS: MARRIED SINGLE MINOR
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1 COOL SPRINGS ALLERGY ASSOCIATES, P.C. / CLARKSVILLE ALLERGY CLINIC 1909 Mallory Lane, Suite Hillcrest Drive, Suite 101 Franklin, TN Clarksville, TN HAROLD F. MOESSNER, M.D. JOSEPH T. BELLEAU, M.D. PATIENT INFORMATION: NAME: MALE FEMALE Last First Middle Initial ADDRESS: MARRIED SINGLE MINOR BIRTH TELEPHONE: HOME WORK: EMPLOYER (or school): GRADE: S.S.# PRIMARY HEALTH CARE DOCTOR: SPOUSE/PARENT/GUARDIAN: PERSON RESPONSIBLE FOR ACCOUNT: NAME: BIRTH RELATIONSHIP: (check one) MOM DAD GUARDIAN SPOUSE SELF SS# TELEPHONE: HOME WORK: ADDRESS: EMPLOYER: INSURANCE: POLICY ID#: GROUP #: EMERGENCY CONTACT: TELEPHONE: (outside of immediate family) HAS ANY MEMBER OF YOUR FAMILY EVER BEEN TREATED IN OUR OFFICE? YES NO WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE? AGREEMENT: As a courtesy, we file insurance provided the patient furnished all information necessary. I understand that the portion of my treatment not covered by insurance is due and payable at each visit. I also understand that my insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the doctor, and that I am still responsible for all fees. If my insurance company has not paid their portion within 60 days of being properly billed, I understand that the balance will become due and payable from me. If I do not pay the entire amount due on my statement within 60 days of the date of service, a late charge may be added to my account for the current monthly billing period. The late charge will be periodic rate of 1.75% per month (or a minimum of $1.00 for all balance under $57.00) which is an annual percentage rate of 21%. Customer, Patient, Borrower, etc. agrees to pay all cost of collection including attorney fees, collection fees, and contingent fees to collection agencies of not less than 35%, such contingency fee to be added and collected by the collection agency immediately upon your default and our referral of your account to said collection agency. CONSENT: I have read the above information and give my permission to the office of Cool Springs Allergy Associates, P.C./Clarksville Allergy Clinic to utilize diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient s medical needs and to file my insurance claims and if need to be forward my medical records to my insurance company if they so require to process any claim on my behalf. This agreement gives Cool Springs Allergy Associates, P.C./Clarksville Allergy Clinic authorization to release necessary information to my pharmacy for new prescriptions or refills to be called in by phone, to contact my home, work place, or any other telephone number I deemed appropriate. Messages may be left on my answering machine or with family members. *** IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT, PLEASE LET US KNOW 24 HOURS IN ADVANCE *** SIGNATURE: WITNESS:
2 COOL SPRINGS ALLERGY ASSOCIATES / CLARKSVILLE ALLERGY CLINIC HAROLD F. MOESSNER, M. D. JOSEPH T. BELLEAU, M.D. (615) PATIENT S NAME Last First Middle ADDRESS TELEPHONE SOCIAL SECURITY # DATE OF BIRTH Marital Status: q Married q Single q Divorced q Widowed REFERRING PHYSICIAN CHIEF COMPLAINT (Please decribe your symptoms in the space provided below) ALLERGY HISTORY: CHECK THE SYMPTOMS THAT PROMPTED YOUR VISIT NOSE & HEAD: CHEST: Referred by: FOR OFFICE USE ONLY Itchy Nose Sneezing Stuffy Nose Runny Nose Post Nasal Drainage Sore Throat Coughing Hoarseness Loss of Voice Headache Sinus Infections Itchy Eyes Red Eyes Watery Eyes Eye Swelling Itching Ears Blocked Ears Wheeze Shortness of Breath Tight Chest Smothering Chest Infection SKIN: Hives Eczema Itching Swelling INSECT STING: Life-Threatening Reaction Chief Complaint: History of Present Illness: Approximately how many years have you had your symptoms: a) Head and nose years b) Chest years c) Skin years Page 1
3 Problems: Seasonal Year round FOR OFFICE USE ONLY Do you have increased symptoms from any of the following? A) ALLERGENS B) IRRITANTS q Mowed grass q Smoke q House dust q Outside dust q Cats q Odors q Dogs q Perfumes q Mold q Paint q Musty places q Fumes q Dead leaves q Hair spray q Hay q Soaps q Pollens q Detergents HEADACHES: q Yes q No q Occasional Location (frontal, top, back, cheeks, temples) or others Frequency (times per week or month) Duration (minutes, hours, days) Character (throbbing, sharp, dull) Relief (e.g., medications, sleep, etc.) Aggravating Factors (stress, infection, etc.) FOODS Food allergies with description of reaction: PREVIOUS ALLERGY EVALUATION Have you seen an allergist before q Yes q No If so, when? Do you have skin test results? q Yes q No (If so, please bring skin test results to our office) Have you ever been on allergy shots? q Yes q No If so, are you still taking them? q Yes q No If not, Approximately how long did you take them? When did you quit? Your last Chest X-ray: Last Sinus X-ray: When? When? Why? Why? Results? Results? Ordered by: Ordered by: Dr. Dr. REVIEW OF SYSTEMS: CONSTITUTIONAL SYMPTOMS: fever, weight loss/gain CNS: headaches, dizziness, numbness, fainting OPH: blurred vision, double vision, photophobia ENT: puritic nose, nasal congestion, PND PULMONARY: SOB, wheeze, chest tightness CARDIAC: chest pains, palpatations, irregular heart beat GI: nausea, vomiting, constipation, diarrhea ENDOCRINE: polyuria, polydypsia, temp instability HEM/ONC/LYMPH: bleeding, swelling, bruising INFECTIOUS: recurrent, difficult to treat, life threatening MUSCULOSKELETAL/RHEUMATOLOGIC: arthritis, muscle weakness myalgia, arthralgia SKIN: puritis, rashes, boils PSYCHIATRIC: depression, insomnia Patient: Page 2 ENVIRONMENTAL SURVEY (please check all that apply) Any Pets q Yes q No Inside house? q Yes q No List Inside Pets: Do you smoke? q Yes q No If no, in past? q Yes q No Anyone else smoke inside the house? q Yes q No Any mold problems in house? q Yes q No Type of heating? q Central q Radiant q Wood q Kerosene q Other:
4 PAST MEDICAL HISTORY List all hospitalizations and surgeries in order of most recent: CAUSE OF HOSPITALIZATION YEAR YEAR What other conditions are you being treated or followed for: Past medical conditions or injuries: If patient is a child, are immunizations up to date? q Yes q No Do you have a living will? q Yes q No MEDICATIONS Please list all current medications you are taking to relieve your ALLERGY symptoms: Please list all OTHER medications you are taking regularly: List any medications you take OCCASIONALLY (e.g. Tylenol, sleeping pill, etc.): DRUG ALLERGIES Please list all medications to which you are allergic: FAMILY HISTORY (Please check any that apply) Mother Father Sisters Brothers Children Others Asthma q q q q q q Hayfever q q q q q q Sinus Problems q q q q q q Immune Deficiency q q q q q q Eczema q q q q q q SOCIAL HISTORY Employment/School: Where are you employed/or where do you go to school? Job Description: Does anything at work bother your allergies? Number of days missed from work/school per year because of allergy, sinus, or asthma problems? If patient is a child, does he/she attend day care? q Yes q No How many people are living at home? Recreation: Please list your favorite hobbies: Patient: Reviewed and discussed Doctor Signature: Date: PAGE 3
5 IDENTIFICATION OF PERSONAL REPRESENTATIVE Name of patient DOB / / I hereby grant the individual named below access to my protected health information. This individual may receive and act upon information received from COOL SPRINGS ALLERGY ASSOCIATES, P.C./ CLARKSVILLE ALLERGY CLINIC. This information may include clinical information about my care, as well as billing information related to my insurance coverage and payment activity for services rendered by COOL SPRINGS ALLERGY ASSOCIATES, P.C./CLARKSVILLE ALLERGY CLINIC. I understand I may revoke this authorization at any time. I understand that I have the right to review the information being disclosed to my personal representative. I also understand that the protected health information released to my personal representative may be further disclosed by the recipient. COOL SPRINGS ALLERGY ASSOCIATES, P.C./ CLARKSVILLE ALLERGY CLINIC cannot guarantee the further safeguarding of the health information after the disclosure. I acknowledge that I have received a copy of COOL SPRINGS ALLERGY ASSOCIATES, P.C./ CLARKSVILLE ALLERGY CLINIC (Dr. Harold F. Moessner, M.D. and Dr. Joseph T. Belleau, M.D.) privacy practice notice regarding privacy of personal health information. Patient signature Date signed / / Requests may be mailed to the following address: 1909 MALLORY LANE, SUITE 308 FRANKLIN, TN OR 251 HILLCREST DRIVE SUITE 101 CLARKSVILLE, TN 37043
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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.
: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:
Thank you for making an appointment with our office. We look forward to serving your visual needs.
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Welcome! Please fill out this Patient Registration
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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 INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
FLIXONASE ALLERGY Non Drowsy Nasal Spray 24 hour Effective Relief and Prevention Available in 60 & 150 sprays
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WELCOME TO TRI-COUNTY EYE CLINIC
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Alldent Dental Center Patient Registration
Patient Registration DATE Patient Name Age Address Home Phone Cell City State Zip Email Social Security # Date of Birth Sex: M F Single Married Divorced Widowed Separated Employed by Occupation Business
HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register
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Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork.
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Agnes Ju Chang, M.D., F.A.A.D.
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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.