PATIENT INFORMATION. Patient Name/Nombre
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1 Patient Information Cont d PATIENT INFORMATION Patient Name/Nombre Birth date/fecha de Nacimeinto Age/Edad Sex/Sexo How do you prefer to be addressed by our physicians and staff? Como prefiere que le llamen los doctores y las personas de la oficina? Address/ Domicilio City, State, Zip/ Ciudad, Estado, Zona Postal Home Phone/ Numero de Telephono Cell Phone/ Numero de Cellular Social Security #/Numero de Seguro Social Drivers License #/ Licencia de Manejar Marital Status/ Estado Civil Employer/ Nombre del Empleador WorkPhone/ Numero de Trabajar
2 Patient Information Cont d Work Address/ Domicilio del Empleador City, State, Zip/ Ciudad, Estado, Zona Postal Occupation/ Ocupacion Nature of Business/ Tipo de Negocio Referred by/ Referido por Is this your Primary Care Doctor/ Es este to Doctor Primario If no, Name of Primary Care Doctor/Si no, Nombre del Doctor Primario. Emergency Contact/ Contacto de Emergencia Name/Phone Nombre/Telefone May we leave a message at your home? With a person On answering machine Podemos dejar mensaje en su casa? Con una persona En la maquina de mensajes May we leave a message at your work? With a person? On voic ? Podemoso dejar mensaje en su trabajo? Con una persona? En el correo de voz? Is this visit related to a Work Injury If yes, Date of Injury Es esta visita relacionada con lesion de trabajo Si si, fecha de lesion
3 Patient Information Cont d Is this visit related to an accident? Is this visit related to an injury? Es esta visita relacionada con accidente? Es esta visita relacionada con lesion? If yes, Date of Accident or Injury Si si, Fecha de Accidente o Lesion Briefly describe circumstances Brevemente describa la circunstancia Responsible Party if other that Patient: Persona Responsable si otra del paciente: Name Rel to Patient Nombre Relacion al Paciente Address Domicilio City, State, Zip Ciudad, Estado, Zona Postal Phone Work Phone Numero de Telefono Telefono del Empleador Employer Occupation Nombre del Empleador Ocupacion
4 Patient Information Cont d Workers Comp Insurance Information: Employer Name Nombre del Empleador Address: Domicilio del empleador City, State, Zip Ciudad, Estado, ZonaPostal Contact Person Phone Persona del Contacto Numero de Telefono Date of Injury Time of Injury Fecha de Lecion Tiempo de Lecion Description of Accident Explicar el Accidente Work Comp Insurance Carrier: Portador del seguro de work comp Claim Adjuster Name: Nombre del Ajustador Claim Adjuster Phone: Telefono del Ajustador Claim Number Numero de reclamo Do you have an attorney? Tiene un abogado? Name of Attorney Nombre del Abogado
5 Patient Information Cont d Address Domicilio City, State, Zip Ciudad, Estado, Zona Postal Phone Fax Telefono Fax
6 Napa Valley Orthopaedic Medical Group, Inc. CONSENT FOR TREATMENT Adult I hereby give Napa Valley Orthopaedic Medical Group, Inc., its physicians, and its medical staff my consent for any necessary medical evaluation and treatment. OR Complete for a Minor I certify that I am a legal guardian of, a minor, and I do hereby give Napa Valley Orthopaedic Medical Group, Inc., its physicians, and its medical staff my consent for any necessary medical evaluation and treatment. INSURANCE ASSIGNMENT I give permission to Napa Valley Orthopaedic Medical Group, Inc. to bill my insurance carrier for services rendered. I understand that this is a service provided by Napa Valley Orthopaedic Medical Group, Inc. I request that payment of authorized Medicare or other insurance company benefits be made directly to Napa Valley Orthopaedic Medical Group, Inc., otherwise payable to me, for any services furnished to me by Napa Valley Orthopaedic Medical Group, Inc. Regulations pertaining to Medicare assignment of benefits apply. I permit a copy of this authorization to be used in place of the original. I understand that I must inform my physician if I know that a party other than Medicare is responsible for paying for my treatment. I understand that I am responsible for my medical bills unless I have verified coverage under an active Worker s Compensation claim. I hereby guarantee payment of all physician/provider charges and understand that any amount not paid by insurance within 60 days of service becomes my personal responsibility unless my injury is covered under an active Worker s Compensation claim. Examples of this would include but not be limited to any coinsurance, deductibles, and copayments. INFORMATION RELEASE I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance, information needed for this or a related Medicare or other insurance company claim. I understand that my signature requests that payment be made and authorizes release of any medical or other information necessary to pay the claim. PAYMENT POLICY It has been explained to me that if I am paying privately for medical treatment, payment of all charges is to be made in full at the time of service unless previous arrangements have been made, and I agree to pay all the charges. If there is a co-payment for the medical service, I understand that it is due at the time of service, and I agree to make this payment. I have carefully read and agree to the above information. Signature: Date:
7 NAPA VALLEY ORTHOPAEDIC MEDICAL GROUP, INC. HEALTH INSURANCE PORTABILTY AND ACCOUNTABILITY ACT (HIPAA) NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a copy (5 pages) of the Napa Valley Orthopaedic Medical Group, Inc. Notice of Privacy Practices. This Notice describes how Napa Valley Orthopaedic Medical Group, Inc. may use and disclose my protected health information, certain restrictions on the use and disclosure of my health care information, and rights I may have regarding my protected health information. Name: Signature: Date: I have been given an opportunity to take a copy of the Napa Valley Orthopaedic Medical Group, Inc. Notice of Privacy Practices to review and hereby voluntarily decline to take a copy for my own review. I have been made aware that Napa Valley Orthopaedic Medical Group, Inc. functions under the guidelines of the Health Insurance Portability and Accountability Act (HIPAA), but do not wish a hard copy of the policy at this time. Name: Signature: Date:
8 New Work Comp Spine Patient Information Form Welcome to the Napa Valley Orthopaedic Medical Group, Inc. Please take some time filling out these forms to assist us in gathering information about your spine injury and work situation. If you require more space please make a note of it and we will discuss it in more detail during your visit. Please answer all questions. If a question does not apply please put an X in the box. If you do not know the answer the please put a? in the box. Name: What is your date of birth? What is your Social Security Number? What is your complete mailing address? General Questions: What is your phone number? What was the date of your injury? Who was your employer at the time of your injury? What is your employer's address? Are you represented by a lawyer? If so what is your lawyer's name and adress? How tall are you? How much do you weight? Are you right or left handed? Right Left Both History of the Injury: Please briefly describe how your injury occurred After your injury did you have pain immeadiatly or did it come on gradually? Did your pain get worse over the next hours or days? Did you report your injury on the date of injury? If not when did you report it? What is the name of the person you reported the injury to?
9 History of Treatment: Where were you first treated for this injury? What medications were you prescribed? Did you receive physical therapy? Where and how many visits? Did it help? Were you taken off work? Were you returned to work with modifications? If so what? Have you had X-rays or an MRI? If so, when were they done and where? Were you refered to any other doctor for treatment? What other treatments have you had? What other treatments have been recomended? Have you had surgery for this injury? If so what surgery have you had and did it help? Overall have the treatments you have received helped you? History of Other Injuries: Prior to this injury did you have any other work related injuries to this part of your body? If yes, please describe the injury. Did you still have symptoms when this injury occurred? Since your injury have you re-injured this part of your body? Have you ever received a disability award for any work related injury? Have you had any other major accidents or injuries? If so please describe.
10 Current Symptoms: What part of your body is currently bothering you? How often does this problem bother you? (every day, once a week, several times a year ) When this problem is bothering you is it constant or does it come and go? From 1-10 rate your pain: Describe your pain eg sharp, burning, achy, deep, dull: Does your pain radiate to another part of your body? If so where? What makes your symptoms better? What makes your symptoms worse? Do your symptoms disturb your sleep? How? What time of the day are your symptoms the worst? What medications are you taking for this problem? Do they help? Do you feel that in the future this problem will get better, stay the same or become worse? What do you think you need in order to get better? Job History: At the time of injury who was you employer? When did you start working for this employer? Before you started this job what other jobs had you done? Did you have any other jobs or employers at the time of injury? Are you still working for this employer? If you are not still working for this employer, why? Have you obtained a new job with a different employer?
11 Job Description: What was your job title? What were you job duties? How many hours a day did you work? How many days a week did you work? What was the maxium ammount of weight you were required to lift on this job? Pain Diagram On the diagram please draw where your symptoms are:
12 Medical History: Please list any medical problems that you have, even if they are under control. Please list any surgeries you have had. Please list any allergies you have to medications or other significant allergies. Please list your current medications (if you have a list, bring it to the receptionist to copy) Please List your pharmacy name and number Please list any major medical problems that run in you family. Relative Disorder/Disease Disorder/Disease Mother Father Brothers/Sisters Other Family Members
13 Social History: Do you smoke? How many packs a day? How long have you smoked? Do you use other tobacco products? Do you drink alcohol? How many drinks do you have a day? Do you use any other drugs? What is your marital status: How many year of school have you completed? Do you exercise? What are your hobbies? Review of Systems: Do you have any of the following symptoms? Category Symptom Yes No General Fever Chills Recent weight loss Recent weight gain history of cancer Eyes Glasses Double Vision Blurry Vision Recent Changes in Vision ENT Hearing Loss Difficulty Swallowing Change in Voice Sinus Infections Respiratory Asthma Emphysema Shortness of Breath GI Acid Reflux Stomach Pain Stomach Ulcers GI Bleeding Liver Problems Hepatitis GU Bladder Infections Difficulty Urinating
14 Loss of Urinary Continence Category Symptom Yes No Musculoskeletal Joint Pain Joint Swelling Weakness Skin Rashes Recent Cuts Neurologic Loss of Balance Loss of Coordination Numbness Weakness Strokes Seizure Psychiatric Depression Anxiety Hematological Blood Clots Bleeding Problems Immune Disorder HIV/AIDS Endocrine Diabetes Has your injury interfered with or cause problems for you in any of the following activities: 1. Self-care, Teeth, Personal Hygiene. 2. Communication 3. Physical Activity 4. Sensory Function 5. Non-Specialized Hand Activities 6. Travel 7. Sexual Function 8. Sleep
15 Thank you for taking the time to fill out this form.
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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
Welcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear
Welcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear If you are a new patient to our practice and would like to complete new patient forms before you arrive, please print
Patient Demographics Sheet
Patient Demographics Sheet PLEASE PROVIDE YOUR PHARMACY INFORMATION BELOW: PREFERRED PHARMACY: PHARMACY LOCATION: PHARMACY PHONE NUMBER: FOR OFFICE USE ONLY Dr. Goldblatt Dr. Brown Last Name: First Name:
CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork
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CAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
Welcome to Tri-State Rehab Services
Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely
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
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
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Welcome to Central Florida Foot and Ankle Center
Welcome to Central Florida Foot and Ankle Center PATIENT INFORMATION Patient Name Address City State Zip Mailing Address City State Zip SS# DL# E-Mail Sex M F Age Birth Married Widowed Single Minor Separated
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?
Creekside Physical Therapy and Rehabilitation
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PATIENT REGISTRATION Date:
PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737 Workers Compensation Form First Name MI Last Name Sex Date of Birth Social Security
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 #:
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
PATIENT INFORMATION FORM. Name: Address: City: State: Zip: Social Security Number: Telephone Numbers Home: Age: Sex: M / F Work: Email: Cell:
PATIENT INFORMATION FORM Name: Address: City: State: Zip: Social Security Number: Telephone Numbers DOB: Home: Age: Sex: M / F Work: Email: Cell: Marital Status: Single Married Spouse s Name: Widowed Divorced
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
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
Function First Physical Therapy, P.C. Patient Intake Form
Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married
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
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
Made to Move Physical Therapy, Inc. 615 N Nash St., Ste # 306 El Segundo, CA 90245 310.535.0008
Name Last First MI Date Current/Permanent address City State Zip Phone H W Cell Email Address: Marital Status Single Married Other Date of Birth: Age: Gender Male Female Spouses DOB: Employer Occupation
Cancellation/No Show Policy
Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You
Luna Spine and Orthopaedic Surgery Mario E. Luna, MD
PATIENT INFORMATION NAME (Last, First, Middle Initial) PRIMARY ADDRESS PATIENT REGISTRATION FORM EMERGENCY CONTACT NAME (Relationship to Patient) CITY, STATE, ZIP CITY, STATE, ZIP PHONE ( ) HOME ( ) CELL
PATIENT INFORMATION. Today s Date. I do not currently carry insurance (initial) Patient s Last Name: Patient s First Name: MEDICAL INSURANCE
PATIENT INFORMATION Please present a Photo ID and ALL insurance cards to receptionist. If items are not presented, full payment will be due at time of service. Please know ALL Co-Pays are due at time of
MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.
MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State:
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! Please complete and sign all of the enclosed forms. Bring these forms, your physician s referral if required and any other documents required
Emory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions