KAHLIL A. SHILLINGFORD, M.D., P.A.
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1 KAHLIL A. SHILLINGFORD, M.D., P.A CENTRAL PARK BLVD., N. BOCA RATON, FL PHONE: (561) FAX: (561) PATIENT INFORMATION NAME: DATE: ADDRESS: CITY: STATE: ZIP: PHONE #: CELL #: SS#: DOB: AGE: RACE: Asian / Caucasian / Black or African American / Hispanic / Unknown ETHNICITY: (Hispanic or Latino): Yes / No LANGUAGE: ADDRESS: S M D PARTNER/SPOUSE NAME: EMPLOYER INFORMATION: EMPLOYER: ADDRESS: WORK PHONE: POSITION:
2 PRIMARY INSURANCE INFORMATION: INSURANCE NAME: ADDRESS: ID#: GROUP: PHONE #: SUBSCRIBER S NAME: SUBSCRIBER S SS#: DOB: SECONDARY INSURANCE: INSURANCE NAME: ADDRESS: ID#: GROUP: PHONE #: SUBSCRIBER S NAME: SUBSCRIBER S SS#: SUBSCRIBER S DOB: REFERRED BY: DOCTOR: PHONE #: ADDRESS: FAX #: OTHER RESOURSE: Assignment of Benefits/Medical Information Release: I request that payment of authorized Medicare/Insurance benefits be made on my behalf to Kahlil A. Shillingford, M.D. for any services furnished to me. I authorize any holder of medical information about me to release any information needed to determine the benefits payable for related services. I hereby authorize Medicare to furnish to the above named doctor any information regarding my Medicare claims under Title XVIII of the Social Security Act. I hereby assign benefits to Kahlil A. Shillingford, M.D./group indicated on this claim. Having insurance is not a substitute for payment. I understand I am financially responsible for any balance not covered by my insurance carrier. A copy of this signature is as valid as the original. SIGNATURE: DATE:
3 EMERGENCY CONTACT: NAME: PHONE #: PATIENT MEDICAL INFORMATION: REASON FOR CURRENT VISIT: ALLERGIES: LIST ALL ALLERGIES AND REACTION: ALLERGIC TO LATEX? YES: NO: REACTION: SMOKER? YES: NO: HOW MUCH? ALCOHOL? YES: NO: HOW MUCH? ILLICIT DURGS? YES: NO: WHAT? CURRENT MEDICATIONS: LIST ALL AND DOSE AND HOW TAKEN: CURRENT MEDICAL CONDITION: PAST HOSPITALIZATIONS: PAST SURGERIES: FAMILY MEDICAL HISTORY:
4 9960 Central Park Blvd., N. I am choosing to enter into medical services with Kahlil A. Shillingford, M.D., P.A. As my appointment time has been set aside exclusively for me, I understand that I am responsible for the appointment fee, or a $25 cancellation fee, if I fail to cancel a scheduled appointment at least 24 hours in advance. I understand that my insurance company will not pay for missed visits. I understand that payment or co-payment is due at the time services are rendered unless special arrangements have been made. I understand the billing department will be glad to file my insurance claims for me; however, payment cannot be guaranteed. I will be responsible for any unpaid balances not covered by my insurance company. Any balance overdue more than thirty days will be subject to a $25 late fee per month. I agree to pay the cost of any delinquent bill, including a reasonable attorney s fee and/or collection agency fee and interest fee. I understand my account may be sent to a collection agency or court if fees are not paid in a timely manner. I fully understand and agree to the above policies and conditions. A copy of this signature is as valid as the original. Patient/Guardian
5 9960 Central Park Blvd., N. As of June 1, 2011, Dr. Kahlil Shillingford will only prescribe medications 30 days post operatively, based on clinical need. Dr. Shillingford reserves the right to discontinue prescription coverage at his discretion; if you believe you are in need of further medications on a long term basis, you must contact your PCP or Pain Management Physician. Patient/Guardian Date
6 9960 Central Park Blvd., N. ATTENTION: Under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. However, certain physicians who meet state requirements are exempt from the financial responsibility law. YOUR DOCTOR MEETS THESE REQUIREMENTS AND HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE. This notice is provided pursuant to Florida law. Patient/Guardian KAHLIL A. SHILLINGFORD M.D., P.A
7 9960 Central Park Blvd. N Medical Records Release Form Date: / / To Whom It May Concern: I hereby authorize any physician, hospital or medical facility the release of any information acquired in the course of my treatment or examination to Kahlil A. Shillingford, M.D. Please fax all recent labs, test results and H&P including diet and exercise history to (561) Patient s Name Patient/Guardian Signature Patient s 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 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
Your appointment is scheduled for at with Dr. Your arrival time is.
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IDENTIFYING INFORMATION Patient Enrollment Form PATIENT NAME: SEX: MALE FEMALE DOB: / / SS# -- -- MO DAY YEAR CONTACT HOME PHONE: EMAIL: WORK PHONE: Preferred method of communication Email Mail Home Phone
THE EYE INSTITUTE. Dear Patient:
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PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)
LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS
The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST
* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable)
Doctor: Patient Name: Address: State: Date of Birth: Home Phone: Work Phone: Zip: Patient Demographics Maiden Name: City: Social Security Number: Cell Phone: Email Address: * Do you wish to receive our
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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
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PATIENT INFORMATION: TODAY S DATE Last Name: Date of Birth: Sex: Male Female First Name: SS#: Middle Initial: Marital Status: Street Address: City: State: Home Phone: Work Phone: Mobile Phone: Email: Contact
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New/Updated Patient Information Please Fill Out Completely: Date: Patient Name: Nickname: First M.I. Last Date of Birth: // Age: SSN: _/_/_ Gender: M F Email: Mailing Address: Marital Status: Single Married
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:
LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.
LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME
PATIENT REGISTRATION FORM
201 N. Park Ave Suite 201 Apopka, FL 32703 Office (407)228-3180 Fax: (407)-228-3725 PATIENT REGISTRATION FORM Last Name: First Name: Middle Initial Male Female Date of Birth: Marital Status: Single Married
Patient Name: Date of Birth: / / Last First Middle I. Home #: Cell #: Work #: Email Address: Primary Care Physician: Phone: Insurance ID #: Group #:
Patient Name: Date of Birth: / / Race: White Black/African American American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Other Ethnicity: Not of Spanish/Hispanic Descent Spanish/Hispanic
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
Medical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
First: M.I. Last: DOB: E- Mail Address (To Access Your Patient Portal): Sex (Circle): MALE/FEMALE Marital Status:
PATIENT DEMOGRAPHICS CENTRAL ILLINOIS ORTHOPEDIC SURGERY, II LLC. LAWRENCE A. NORD, M.D. & BRETT L. KELLER, D.O. 1505 EASTLAND DRIVE * SUITE 220 * BLOOMINGTON, IL 61701 PHONE: 309.662.CAST (2278) * FAX:
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
How To Treat A Medical Condition
FAMILY PSYCHOLOGY ASSOCIATES NEW PATIENT INFORMATION SHEET PATIENT S NAME: DOB: ADDRESS: (street) (apt#) (city) (zip) PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN
The Healthy Mind PSYCHIATRIC SERVICES
The Healthy Mind PSYCHIATRIC SERVICES 900 Straits Tpk Suite D Middlebury, CT 06762 New Patient Registration: Patient s First Name Last Name Patient s Telephone: Home Cell Email: Patient s Date of Birth:
PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT
Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex: