Sneeze, Allergy & Cough Centers

Size: px
Start display at page:

Download "Sneeze, Allergy & Cough Centers"

Transcription

1 PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Sex Single Married Widowed Divorced Address/City/State/Zip Occupation (if minor, guardians occupation) Home phone Employer Name Work phone Address/City/State/Zip Name of Spouse or Parent Home phone Address/City/State/Zip Work phone Occupation Employer Name of the Insured Party Address/City/State/Zip Social Security # DOB Home Phone Work Phone **How did you hear about us? FINANCIAL POLICIES **Payment is due at the time services are rendered. **We will see that you get the best medical care and will make every reasonable effort to aid you in obtaining the maximum benefits allowed with your insurance coverage. ASSIGNMENT AND RELEASE I authorize my insurance benefits to be paid to the physician. I understand that I am responsible for any deductibles, co-insurance, and non-covered services. I also authorize my physician to release any information required to process insurance claims. Name Date 1

2 2 Sneeze, Allergy & Cough Centers REVIEW OF SYMPTOMS Please circle any of the following symptoms that you are currently experiencing or that you have had recently: Constitutional: Fever, weight loss, weight gain, night sweats, severe itching, loss of appetite, fatigue, cold intolerance and or heat intolerance. Eye, Ear, Nose or Throat: Dry eyes, itchy eyes, vision changes, cataracts, glaucoma, light avoidance, eye pain, eye discharge, itchy ears, ear infections, ringing in ears, loss of balance, loss of hearing, deviated septum, nose bleeds, post nasal drip, nasal congestion, sore throat, hoarseness, difficulty swallowing, recurrent throat infections, loss of smell and or taste, dry mouth, dental cavities. Lungs: Lymph Nodes: Heart: Intestinal tract: Reproductive: Urinary: Shortness of breath, cough, nighttime coughing, coughing up blood, wheezing, chest congestion, chest tightness, hard to catch your breath. Swelling, tenderness. Chest pain, palpitations, swelling of ankles, inability to lie flat in bed. Nausea, vomiting, heartburn, indigestion, trouble swallowing liquids or fluids, abdominal pain, constipation, diarrhea, excessive gas, food intolerance, acid or sour taste in mouth, blood in stool or jaundice. Irregular periods, skipped periods, unusual vaginal bleeding, menopause, infertility, miscarriages, impotence, unplanned pregnancy, planned pregnancy. Kidney stones, inability to urinate, prostate problems, kidney infections. Rheumatologic & Orthopedic: Early morning stiffness, joint swelling, joint pain, gout, low back pain, osteoporosis, fractured bones. Skin: Neurologic: Skin rash, hives, eczema, skin tumors or growth, excessive hair loss. Fainting spells, severe headaches, epilepsy (seizers), difficulty with memory, inability to concentrate. Provide explanation on any symptoms that are particularly bothersome to you: Patient Signature: Date

3 3 Sneeze, Allergy & Cough Centers Patient Name: Date of Birth: Date of Visit: TB Screening Questionnaire In the last year, have you experienced any of the following symptoms for more than three weeks at a time? SIGN & SYMPTOM REVIEW: YES NO Persistent cough Excessive sweating at night Unexplained weight loss Coughing up blood Excessive fatigue Persistent fever

4 4

5 5

6 6

7 7

8 8

9 9 Sneeze, Allergy & Cough Centers Acknowledgment and Consent (initial) Consent to Treatment I consent to the performance of diagnostic procedures, examinations and rendering of treatment by the medical provider and their designated medical office staff as is deemed necessary in the medical provider s judgment. (Initial) Immunotherapy Treatment Options My treatment options have been explained to me including rapid desensitization versus traditional immunotherapy and the cost difference between these therapies. I understand that rapid desensitization or cluster therapy requires an office visit be charged for each session and that a copayment will be required. (Initial) Insurance Contract I understand that SACC has a contract with the insurance carrier which requires them to bill all applicable copayments, coinsurances, and deductibles to the patient/insured as directed by the carrier. Requests for adjustment of these obligations is in direct violation of these insurance contracts and could jeopardize the physician and practices participating provider status. Therefore these requests cannot be accepted. Please make sure you understand your financial obligation and insurance coverage before beginning any treatment. (initial) Financial Policy I authorize the release of any medical information necessary to process an insurance claim on my behalf. I understand that I am financially responsible for all charges and that I am responsible for obtaining any referrals required by my insurance carrier. I request that my medical insurance carrier make any payment directly to SACC for services rendered to me. As a courtesy, my charges will be filed with my insurance carrier; however, I will be billed if the claim is denied or is not paid in a timely manner. I also understand that I am encouraged to check my benefits prior to my appointment and that although I may receive an explanation of benefits, that this is not a guarantee of coverage. 1. There is a $25.00 fee for returned checks. 2. There is a $ fee for MISSED new patient appointments or for new patient appointments CANCELLED less than 24 hours prior to the scheduled appointment. 3. There is a $50.00 fee for missed follow-up appointments and appointments CANCELLED less than 24 hours prior to the scheduled appointment. Uncovered services: We at SACC provide world-class care for our patients. Accordingly, some of the services we provide have been deemed uncovered by many private insurance carriers. Since these charges are often not covered by insurance, we directly bill these services to our patients. Such uncovered services include (but are not limited to) telephone correspondence(s) over 10 minutes / encounter(s) of any nature, telephone prescription or refill requests and internet/web-based correspondence(s) and encounter(s).

10 10 Sneeze, Allergy & Cough Centers (initial) Release of Medical Information I, (print patient name), have read a copy of SACC s Notice of Privacy Practices. (This document is available at our front desk or at I authorize information to be released to the following individuals: Name: check one: [ Medical] [ Financial] Name: check one: [ Medical] [ Financial] Name: check one: [ Medical] [ Financial] I,, have read and understand the above and agree to the terms stated above. Responsible Party Signature SACC Staff Signature Date Date

Personal Injury Questionnaire

Personal Injury Questionnaire Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer

More information

Review Of Systems. 1. General Weight Weight 1 year ago Maximum weight When Height Fatigue/Weakness Y P N Fever/Chills Y P N

Review Of Systems. 1. General Weight Weight 1 year ago Maximum weight When Height Fatigue/Weakness Y P N Fever/Chills Y P N Review Of Systems Y N P a condition you have now a condition you have NEVER had a condition you have had in the past Responses and Comments: 1. General Weight Weight 1 year ago Maximum weight When Height

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label) REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please

More information

Tests / Procedures Date Where was procedure done?

Tests / Procedures Date Where was procedure done? New Patient Worksheet For Appointment Scheduled with: Date: Time: Personal Information (Please PRINT and complete all sections) Patient Name Date of Birth Address Gender M F City St E-mail Zip Phone Cell

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION (mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

More information

Patient History Questionnaire Comprehensive Breast Care Center

Patient History Questionnaire Comprehensive Breast Care Center Patient History Questionnaire Comprehensive Breast Care Center Patient Name of birth Age Occupation Today s Height Weight Primary Care Physician: OB/ GYN: Referring Physician: Who else may we send a medical

More information

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in

More information

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.

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

More information

Medical Intake Form. Name Age Birthdate Sex. Address City Zip. Phone (H) (W) Occupation Full Time / Part Time. Employer Education Level

Medical Intake Form. Name Age Birthdate Sex. Address City Zip. Phone (H) (W) Occupation Full Time / Part Time. Employer Education Level Medical Intake Form Please complete all of the following as accurately as possible: Name Age Birthdate Sex Address City Zip Phone (H) (W) Occupation Full Time / Part Time Employer Education Level Married

More information

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Age: Date: Address: Telephone Number: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)

More information

TRIGEMINAL NEURALGIA QUESTIONNAIRE

TRIGEMINAL NEURALGIA QUESTIONNAIRE TRIGEMINAL NEURALGIA QUESTIONNAIRE Name: Date of birth: E-mail address: Address: Contact phone # s: (H) (W) (C) Medical Insurance: Name of Carrier Membership ID# Group# Primary Care Physician Information:

More information

REVIEW OF MEDICAL HISTORY

REVIEW OF MEDICAL HISTORY Patient s Name: Today s Date: Family Physician or Pediatrician: Physician s Phone Number: Physician s Address: Please Tell Us How You Found Our Practice Check ( ) those that apply: Physician Referral Internet

More information

PATIENT SELF-ASSESSMENT FORM

PATIENT SELF-ASSESSMENT FORM PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:

More information

Plano Heart Center, P.A.

Plano Heart Center, P.A. Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:

More information

17191 St Luke s Way Suite 220 The Woodlands TX 77384

17191 St Luke s Way Suite 220 The Woodlands TX 77384 Dear Patient: Thank you for choosing Dr. Menga for your Rheumatology care. In order to expedite the check in process, please review and complete all enclosed documents prior to your appointment. Please

More information

CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD

CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you

More information

Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email 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

More information

Rehabilitation Medicine Clinic. New Patient Questionnaire

Rehabilitation Medicine Clinic. New Patient Questionnaire Rehabilitation Medicine Clinic (Please complete this 5-page form and bring to your appointment.) Date Appt. Date Age Date of Birth Name Male Female Hand dominance: R L Home Address Home Phone ( ) Work

More information

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003) SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty

More information

Pulmonary Associates of Richmond

Pulmonary Associates of Richmond Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment

More information

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last

More information

General Internal Medicine Clinic New Patient Questionnaire

General Internal Medicine Clinic New Patient Questionnaire General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:

More information

Workman s Compensation

Workman s Compensation Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken

More information

1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU

1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood

More information

Candida Questionnaire and Score Sheet. If you d like to know if your health problems are yeast connected, take this comprehensive questionnaire.

Candida Questionnaire and Score Sheet. If you d like to know if your health problems are yeast connected, take this comprehensive questionnaire. Anne Baker CN, LE Nourish Holistic Nutrition Therapy Coach www.nourishholisticnutrition.com nourishnutriton@comcast.net 248 891 5215 Candida Questionnaire and Score Sheet If you d like to know if your

More information

Neuro-Opthamalogy. USF Eye Institute and Ear, Nose and Throat Center. Dear Neuro-ophthalmology Patients:

Neuro-Opthamalogy. USF Eye Institute and Ear, Nose and Throat Center. Dear Neuro-ophthalmology Patients: USF Eye Institute and Ear, Nose and Throat Center Neuro-Opthamalogy Dear Neuro-ophthalmology Patients: The following information is to prepare you for your visit with Dr. Drucker. If you have had an MRI,

More information

Emory Eye Center New Patient Questionnaire

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

More information

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)

More information

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas

More information

Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip

Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip Texas Sinus Center PATIENT REGISTRATION 1. PATIENT INFORMATION Name Birth date Soc Sec# Address City/State Zip Home Phone Work Phone Cell Phone Marital Status S / M / W / D Student FT / PT Male / Female

More information

Copayment Is Due At Time Of Visit. Self-pay (payment due at time of service)

Copayment Is Due At Time Of Visit. Self-pay (payment due at time of service) REGISTRATION FORM Please present your insurance card and photo ID at time of check-in. Settlement of patient financial responsibility is expected at time of service. Copayment Is Due At Time Of Visit.

More information

Cervical Spine. New Patient Form

Cervical Spine. New Patient Form Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right

More information

Beach Family Doctors Medical Group

Beach Family Doctors Medical Group Beach Family Doctors Medical Group Welcome to our practice! Office Hours / After Hours 8:30am-5:00pm Monday through Friday; Closed for lunch; Closed all major holidays. For urgent medical issues after

More information

CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD

CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you

More information

PATIENT DEMOGRAPHICS

PATIENT DEMOGRAPHICS PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient

More information

PATIENT REGISTRATION

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

More information

New Patient Intake Form

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

More information

MEDICAL EVALUATION. Metabolic EVALUATION. NUTRITIONAL and Activity EVALUATION

MEDICAL EVALUATION. Metabolic EVALUATION. NUTRITIONAL and Activity EVALUATION Pioneer valley weight loss centers 2 Medical Center Drive Suite 202 Springfield, MA 01107 (413) 205-1200 Fax (413) 205-1220 www.pvweightloss.com Pioneer Valley Weight Loss Centers was developed to give

More information

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.

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:

More information

PATIENT HISTORY FORM

PATIENT HISTORY FORM PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your

More information

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration

More information

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

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:

More information

PATIENT HEALTH QUESTIONNAIRE: Urology

PATIENT HEALTH QUESTIONNAIRE: Urology PATIENT HEALTH QUESTIONNAIRE: Urology Patient Name: Sex: M F Last, First, Middle Initial Email: Date of Birth: \ \ Age: Social Sec #: - - Type of visit: Consultation requested by another Physician Self-referred

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:

More information

7. X-Rays provided in our office will be billed as an outpatient service of Florida Hospital Flagler. Statement of Policies

7. X-Rays provided in our office will be billed as an outpatient service of Florida Hospital Flagler. Statement of Policies Statement of Policies The following policies are established for mutual convenience and benefit. Please read them carefully and sign at the bottom to indicate your agreement of the statement of policies.

More information

Florida Digestive Specialists Gastroenterology and Liver Disease Management Over 30 Years of Service

Florida Digestive Specialists Gastroenterology and Liver Disease Management Over 30 Years of Service It is a pleasure to welcome you to Florida Digestive Specialists (Formerly Gastroenterology and Oncology Associates)! We strive to exceed your expectations and provide you with the best service possible.

More information

Fran, Medical Assistant Kim, Office Manager, Referral Coordinator, Billing Specialist

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

More information

Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527

Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527 Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684

More information

Orthopedic Patient Information

Orthopedic Patient Information Orthopedic Patient Information Please complete the following questionnaire. It is designed to assist our providers with your care and better understand your medical information. Please answer every section.

More information

71 Spit Brook Road, Suite 407 Nashua, NH 03060

71 Spit Brook Road, Suite 407 Nashua, NH 03060 71 Spit Brook Road, Suite 407 Nashua, NH 03060 Welcome! I look forward to helping you to meet your health goals. Please take a few minutes to fill out this questionnaire to help me to serve you better.

More information

WORKERS COMPENSATION INFORMATION

WORKERS COMPENSATION INFORMATION WORKERS COMPENSATION INFORMATION PATIENT REGISTRATION INFORMATION 15215 Shady Grove Rd. # 100 Patient Name: Last First MI Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Primary Doctor:

More information

DO NOT MAIL BRING DAY OF APPOINTMENT PLEASE BRING ALL CURRENT MEDICATIONS

DO NOT MAIL BRING DAY OF APPOINTMENT PLEASE BRING ALL CURRENT MEDICATIONS DO NOT MAIL BRING DAY OF APPOINTMENT PLEASE BRING ALL CURRENT MEDICATIONS Department of Rheumatology James Brown, M.D. Brian Kirby, M.D. Nancy Morris, M.D. Michael VandenBerg, M.D. Medical Center Clinic

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)

More information

PATIENT DEMOGRAPHICS:

PATIENT DEMOGRAPHICS: PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?

More information

OrthoVirginia Registration Information 2016

OrthoVirginia Registration Information 2016 OrthoVirginia Registration Information 2016 Patient Information Patient Name Account # Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex Male Female City, State

More information

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)

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

More information

Pain Questionnaire. Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495

Pain Questionnaire. Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495 Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495 Pain Questionnaire Date First name Last name Middle initial Date of birth Sex Male Female Height Weight

More information

USF DEPARTMENT OF CARDIOLOGY NEW PATIENT INTAKE FORM

USF DEPARTMENT OF CARDIOLOGY NEW PATIENT INTAKE FORM Personal Data Name: Date: Date of Birth: Age: Occupation: Marital Status: Single Married Divorced Widowed Birth Place: Education Level: Reason for Cardiac Referral: Physician referring for Cardiac assessment:

More information

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Pharmacy: Pharmacy Phone #:

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Pharmacy: Pharmacy Phone #: PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally

More information

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE

More information

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:

More information

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: 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

More information

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:

More information

Riverwalk Physical Therapy, L.L.C. ACUPUNCTURE HEALTH HISTORY QUESTIONNAIRE

Riverwalk Physical Therapy, L.L.C. ACUPUNCTURE HEALTH HISTORY QUESTIONNAIRE Riverwalk Physical Therapy, L.L.C. ACUPUNCTURE HEALTH HISTORY QUESTIONNAIRE Name: Date: Street: City: State: Zip: Cell Phone: Home Phone: Occupation: Marital Status: Date of Birth: Age: Gender: M F Height:

More information

Princeton and Rutgers Neurology, P.A. A Center Of Excellence

Princeton and Rutgers Neurology, P.A. A Center Of Excellence DEMOGRAPHICS Patient s Last Name: First Name: Address: City: State: Zip Code: Tel # (Cell): Tel # (Home): Tel # (Work) #: Preferred Method Of Contact: [] Cell Phone [] Home Phone [] Work Phone SS #: /

More information

HAROLD F. MOESSNER, M.D. JOSEPH T. BELLEAU, M.D. NAME: MALE FEMALE ADDRESS: MARRIED SINGLE MINOR

HAROLD F. MOESSNER, M.D. JOSEPH T. BELLEAU, M.D. NAME: MALE FEMALE ADDRESS: MARRIED SINGLE MINOR COOL SPRINGS ALLERGY ASSOCIATES, P.C. / CLARKSVILLE ALLERGY CLINIC 1909 Mallory Lane, Suite 308 251 Hillcrest Drive, Suite 101 Franklin, TN 37067 Clarksville, TN 37043 HAROLD F. MOESSNER, M.D. JOSEPH T.

More information

Patient Medical Summary

Patient Medical Summary Patient Medical Summary Date of Visit: Referring Physician: Reason for today s visit (chief complaint): What is/are the chief area(s) of pain? Please check all those that apply. Head Neck Upper back Lower

More information

PAST MEDICAL HISTORY REVIEW OF SYSTEMS

PAST MEDICAL HISTORY REVIEW OF SYSTEMS SOUTHEASTERN SPORTS MEDICINE Page 1 of 6 21 Turtle Creek Drive Asheville, NC 28803 DATE PATIENT INFORMATION PATIENT NAME: Last First Middle ( ) Child ( ) Single ( ) Married ( ) Widow(er) ( ) Divorced Address

More information

Edward M. Stroh, M.D., P.C. Retina Consultants of Long Island Page 1

Edward M. Stroh, M.D., P.C. Retina Consultants of Long Island Page 1 Edward M. Stroh, M.D., P.C. Retina Consultants of Long Island Page 1 Please fill out completely Legal Name First: Middle: Last: City: State: Zip: Home #: Cell #: Work #: Email: Spouse DOB DOB: Sex: SS

More information

Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600

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

More information

PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient

PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient PATIENT INFORMATION Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address Emp. Phone Spouse/Partner

More information

AGREEMENT AND INFORMATION

AGREEMENT AND INFORMATION AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.

More information

Your Vision, Your Life. Gina R. Cottle, M.D. 11614 Bee Cave Rd. (FM 2244) Suite 110 Austin, TX 78738

Your Vision, Your Life. Gina R. Cottle, M.D. 11614 Bee Cave Rd. (FM 2244) Suite 110 Austin, TX 78738 Your Vision, Your Life Gina R. Cottle, M.D. 11614 Bee Cave Rd. (FM 2244) Suite 110 Austin, TX 78738 Phone 512-263-1113 Fax 512-263-1119 www.lakeaustineye.com Dr. Mrs. Ms. Mr. First Name M.I. Last Sex:

More information

CAMARILLO AQUATICS AND REHABILITATION SERVICES

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

More information

Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:

Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work: Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out

More information

Surgery Health Survey

Surgery Health Survey Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:

More information

Consent by Proxy for Non Urgent Pediatric Care

Consent by Proxy for Non Urgent Pediatric Care Consent by Proxy for on Urgent Pediatric Care Patient ame: DOB: Patient ame: DOB: Patient ame: DOB: Patient ame: DOB: I (we) appoint as our proxy decision maker: ame: Relationship to patient: ame: Relationship

More information

Florida Eye Center Patient Registration Form (Please Print Clearly)

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:

More information

INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION

INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan

More information

Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:

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

More information

Women s Continence and Pelvic Health Center

Women s Continence and Pelvic Health Center Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire

More information

PATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Email Address:

PATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Email Address: NEW HAMPSHIRE GASTROENTEROLOGY, INC. 9 Washington Place, Suite 204, Bedford, NH 03110 Office: 603-625-5744 Fax: 603-606-3049 ** Please return this form completed ASAP** PATIENT INFORMATION Name: DOB: DATE:

More information

Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use

More information

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

Dallas Neurosurgical and Spine Associates, P.A Patient Health History Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

More information

Cardiovascular Genetics Clinic Cardiomyopathy Questionnaire

Cardiovascular Genetics Clinic Cardiomyopathy Questionnaire Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Primary Care Physician: Why have you been referred for a Cardiovascular Genetics Appointment? Have you had a genetics evaluation? If

More information

Once again welcome to our office!

Once again welcome to our office! !"#%&'()(*+,-..(/0&'#., (1,2(3'",4#5&.6666666666666666666666666666666666666666666,,,,,,,,,,,,!!"#%&'()*+,-.'(/!01 23'45&,67890:9 ;1?8>00?? 2@A=1#!>1?8>##01 BCD%EFC!"#%&#'((((((((((((((((((()))*++,&#-%&#)."#%)/)#-%'((((((((((((((0(((((((()

More information

MEDICINES TO CONTINUE TAKING PRIOR TO ALLERGY TESTING

MEDICINES TO CONTINUE TAKING PRIOR TO ALLERGY TESTING 5929 S. Fashion Point Dr. Suite 101, South Ogden, UT 84403 (801) 476-0052 fax (801) 476-0064 The physicians and staff of Intermountain Allergy & Asthma welcome you to our practice! The following information

More information

New Patient Registration Information

New Patient Registration Information New Patient Registration Information Form 8026 5/09 3038 PR&C Dear WellSpan Orthopedics Patient: Welcome to WellSpan Orthopedics. Thank you for allowing us the opportunity to assist with your health care

More information

ALLERGY HISTORY QUESTIONNAIRE

ALLERGY HISTORY QUESTIONNAIRE Department of Otolaryngology / Head and Neck Surgery Division of Allergy and Environmental Disease ALLERGY HISTORY QUESTIONNAIRE Name: Date: Occupation: Have you ever been tested for allergies? Yes No

More information

Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone

Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address

More information

RALEIGH NEUROSURGICAL CLINIC, INC.

RALEIGH NEUROSURGICAL CLINIC, INC. Revised 09/26/14 PATIENT INFORMATION RALEIGH NEUROSURGICAL CLINIC, INC. Age: Sex: M F Date Last Name First Name Middle Initial Mailing Address City State Zip Social Security # Home Phone ( ) Cell Phone

More information

319 Airport Road Hackettstown, NJ 07840 Ph: 908-850-0888 / FAX: 908-850-1005

319 Airport Road Hackettstown, NJ 07840 Ph: 908-850-0888 / FAX: 908-850-1005 319 Airport Road Hackettstown, NJ 07840 Ph: 908-850-0888 / FAX: 908-850-1005 Dear New Patient: Thank you for choosing Holistic Family Healthcare as your holistic healthcare provider. Our goal is to help

More information

Darius Peikari, M.D. Internal Medicine

Darius Peikari, M.D. Internal Medicine Thank you for selecting Darius Peikari, M.D., PA for your healthcare needs. Please fill out the enclosed paperwork and bring it in with you when you come for your appointment. Also, be sure to bring your

More information

Patient Medical History Form

Patient Medical History Form Patient Medical History Form Patient Name: To help the doctor serve you better, please complete the information below. Thank you! Allergies: No known Allergies (If yes, please list all Drug, Food, and

More information

New Patient Packet. Welcome and thank you for choosing Provident Healthcare. Please complete this packet and bring it with you to your first visit.

New Patient Packet. Welcome and thank you for choosing Provident Healthcare. Please complete this packet and bring it with you to your first visit. New Patient Packet Welcome and thank you for choosing Provident Healthcare. Please complete this packet and bring it with you to your first visit. For your reference, you may want to write down your appointment

More information

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

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)

More information

For the Patient: Cetuximab Injection Other names: ERBITUX

For the Patient: Cetuximab Injection Other names: ERBITUX Traditional Chinese For the Patient: Cetuximab Injection Other names: ERBITUX Cetuximab (se tux i mab) is a drug that is used to treat some types of cancer. It is a monoclonal antibody, a type of protein

More information

OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD

OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -

More information

that will be helpful to you in your interaction with our office. Please read this prior to your visit.

that will be helpful to you in your interaction with our office. Please read this prior to your visit. .) We look forward to your visit with us. We would like to provide you with infonnation that will be helpful to you in your interaction with our office. Please read this prior to your visit. OFFICE HOURS:

More information

Allergies to Medications: Yes ( ) No ( ) if yes, explain: Allergies to environmental agents: Yes ( ) No ( ) if yes, explain:

Allergies to Medications: Yes ( ) No ( ) if yes, explain: Allergies to environmental agents: Yes ( ) No ( ) if yes, explain: Accredited by the American Academy of Sleep Medicine Sleep History Questionnaire Name: Ht: Wt: Neck Size: Allergies to Medications: Yes ( ) No ( ) if yes, explain: Allergies to environmental agents: Yes

More information