Syeda N. Sultana, M.D. Board Certified Child, Adolescent & Adult Psychiatrist
|
|
- Gabriel Baker
- 7 years ago
- Views:
Transcription
1 Patient's First Name: Middle Name: Last Name: Sex: Marital Status: of Birth: Social Security Number: Patient's Address: Home Phone: Address: Primary Care Physician: Pharmacy: Mobile Phone: Referred by: Primary Care Physician Phone: Pharmacy Phone: Pharmacy Address: Employer/School: Employer/School Phone: Emergency Contact Name: Occupation: Employer/School Address: Emergency Contact Phone: Relationship to Patient: Primary Health Insurance Company: Plan: Plan Number: Group Number: Insured Employer/School: Relation to Patient: Insured's Address: Insured's Name: Insured's Phone Number: Insured's Social Security Number: Insured's Birthdate: 1
2 Responsible Party (If other than the patient): Billing Name: Relation to Patient: Reason For Visit: Phone: Address: Symptoms Started: List any current medications: Have you lost any days from work or school: How much caffeine do you drink per day: Are you currently employed: How would you identify your sexual orientation: How often do you exercise: Have you ever served in the military: Have you ever been arrested: Do you have any pending legal problems: Do you belong to a particular religion or spiritual group: Highest Educational Level Attained: Scheduling Appointments: Please prepare to confirm your appointment with Visa or Master Card; we will charge $1 on the card and keep it on file. Self-pay patients need to make the full payment to confirm appointment. There are charges to fill up paper work please see the payment agreement form. Our practice will always accommodate your scheduled time how ever due to the complexcity and emergency condition of the patient ahead of you, there may a delays or a long delays which circumstance is out of our hand. We appreciate your patience and cooperation during these times. Our staff will do everything possible to provide the best treatment you and your family needs. Please let us 2
3 know your urgency upon arrival for your visit. We request new patient to 35 minutes prior to the appointment time and 10 minutes prior to your follow up visit. The appointment is final. We may try to have courtesy reminder call for your schedule appointment. Patient is responsible to keep the appointment to avoid no show fees. What to Bring: We will need you to bring all your medication with the container with patient name and prescribing provider's information. We will need you to fill and bring these forms on our website prior to the time of your appointment. Also please fax or your Authorization for Release of Medical Record s Information to Previous Practitioner (Primary Care Doctor / Psychiatrist) * Authorization for Care & Treatment, HIPAA Regulation & Consent, Payments Agreement, Patient Questionnaire, Release of Medical Records Form. We must have your current valid Photo ID, if there is a Child or Adolescent, we will need Child s school Photo ID, prior Medical Records, prescribed medication with container and your copayment prior to the visitation with the provider. If you are adoptive parents, Care providers, Step Parents or Custodial Parents we will need official court order, adoption paper, official court orders with the authorization for the medication and treatment of the child and Adolescent patients. For a New Child or Adolescent patient we must have an initial visit with the parents only and then we will have an initial visit with the Child or Adolescent patient with the parents. The parents must bring the patient only no sibling at the time of the visit. For the Adult treatment of ADHD or ADD the provider s requires neuropsychological testing and urine drug screens before start of stimulant medications. 3
4 For the prior authorization of medication there may be a fees and will take 7 days to get approval by the prescription insurance company. Our office prescribe medication for 30 days only and requires a follow up visit to receive prescription. We must have the fees prior to the initiating FMLA/any paper work Office Policy: If the patient misplaces (including lost or stolen) a control substance prescription within the time period before the next appointment, the prescribing physician will not write another prescription. It is the patient s or guardian's sole responsibility to keep the prescription in a safe protected place. The call in prescription fees will be charged only if the patient requires a refill. For the safety of our patients and staff, please do not bring any food or drink, any concealed weapons, or any sharp items. Any photography and/or video recording is prohibited. Insurance DOES NOT cover over the phone conversations. If you need to have your appointment over the phone, conversations and therapies are charged at a $390 self-pay rate. Any patient with litigation must pay for all the litigation fees arising between the parties. They must indemnify and hold harmless to Bay Hill Psychiatric Associates, its staff, Dr. Syeda Sultana and all the providers for litigation, court ordered subpoenas, and compliance of court orders. We thank you for your patience and appointment request we will get back to as soon as possible to confirm you appointment. Please type and print your name below as an acknowledgement of all the terms and condition regarding your appointment with our office: Patient/Guardian Signature: Print Name: Patient of Birth: : 4
5 AUTHORIZATION FOR CARE AND TREATMENT Patient: Therapist: Syeda N. Sultana, M.D. of Birth: 1. I recognize that a condition exists requiring psychiatric/psychological care and do herby voluntarily consent to such care, medical care and treatment and diagnostic procedures by Bay Hill Psychiatric Associates, LLC (medical professional staffs, employees & agents) or as deemed necessary. 2. I hereby authorize the physician assigned, as provided by law, to furnish psychiatric/psychological care or therapy, including administration of psychiatric medication. 3. I am aware that the practice of medicine, including psychiatry and psychology, are not exact sciences, and I acknowledge that no guarantees have been made to me as to the result of diagnostic procedures, medical procedures, treatments, examinations or care undertaken. 4. The contents of this form have been fully explained to me and I have been given the opportunity to ask questions. Any questions which I have asked have been answered to my satisfaction. I certify that I understand the contents of this form and that all blanks have been crossed out or filled in. I UNDERSTAND THAT I AM ENTITLED TO AN EXACT COPY OF THIS AGREEMENT. Signature of Patient Witness Signature of patient s parent/guardian if the patient is under 18 years of age. This form has been filled out and explained to the person whose signature appears: Signature of Patient Witness 5
6 HIPPA REGULATION AND CONSENT: Required by the Health Insurance Portability and Accountability Act CFR Parts 160 and 164 I have previously received the HIPAA regulation and do not wish to receive a copy today. I have received a copy of the HIPAA regulation today Signature I hereby request the following regarding the use of my Personal Health Information: You may leave the following message on answering machines: 1. Referral information 2. Prescription refill information 3. Test results 4. Appointment reminder 5. All of the above You may contact me regarding my treatment and care at the following numbers: Home: Cell: Work: You may talk to the following people in my family about care, appointment, test results, etc: Name: Phone: Relation: Name: Phone: Relation: Witness: : If minor is unable to sign for himself/herself: Signature of the guardian: Witness: : : 6
7 PAYMENTS AGREEMENT: I clearly understand and agree that all services rendered to me personally and/or to a minor or other person under my guardianship are charged to my credit card directly to me and I am financially responsible for payment for the office visit. There are no refunds or charge backs for the services, (No show fees)missed appointments and other charges below: ASSIGNMENT AND RELEASE I, the undersigned have insurance coverage with: began: (Insurance company) All medical benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Medicare/the Insurance Company. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all my insurance/financial institution submissions whether manual or electronic: Signature: I have read, understand and accept the payment instructions given to me at this time of my first visit. THIS SIGNED FORM WILL SERVE AS MY SIGNATURE ON FILE, UNLESS OTHERWISE SPECIFIED. I GIVE PERMISSION TO DR. SYEDA N. SULTANA TO TREAT ME/MY CHILD AS HER PATIENT IN HER OFFICE UNLESS OTHERWISE SPECIFIED IN WRITING. Signature: I am responsible as a self-pay patient an initial visit of $ & follow up visits at $ paid in advance at the time of Appointments. All Market place Insured patient may have to pay self pay rate until we receive payment from insurance company. After reviewing the EOB the refund will be provided to the Credit Card it was charged originally. If my insurance company refuses to confirm payment or my insurance expired at the time of my visit a selfpay visit rate will be charged to the credit card on file for the services. CANCELLATION AND OTHER CHARGE POLICY: I understand that I will be charged for appointments not kept and which were not canceled 48 hours (2 business days, excluding Tuesday) in advance of the appointment time. Since insurance companies cannot be billed, I will pay for missed appointments, and I am personally responsible and authorizing no show fess to be charges to my credit card on file for such payment(s). $ charge for new patient missed appointments; a $ charge for follow-up missed appointments. $230 for the self pay patient. $ charge for refill without office visit, call in or lost prescription, for returned check, any personal letters & any forms filled by the doctor. $ charge for short term, long term, Medicare, Social Security, disability, any insurance company, CPA, court, attorney & FMLA documents. Initials: I HEREBY AUTHORIZE SYEDA N. SULTANA, M.D. / BAY HILL PSYCHIATRIC ASSOCIATES, LLC TO RELEASE ALL INFORMATION NECESSARY TO SECURE PAYMENT AND ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND ACCEPTED THE FORGOING STATEMENTS. Signature: : DOB: Print name: SS#: D. License #: 7
8 RELEASE OF INFORMATION Required by the Health Insurance Portability and Accountability Act CFR Parts 160 and 164 I hereby Authorize: Bay Hill Psychiatric Associates, LLC Syeda N. Sultana, M.D. Fax: To: a. Release information to: Doctor s Name: b. Obtain information from: Office Name: c. Exchange information with: Address: Phone: Fax: The information requested or authorized for release or exchange pertains to: a. Mental Health b. Education c. HIV/Transmitted disease d. Drug or alcohol abuse This authorization is valid for 90 days from the date below or, whichever is earlier. I may cancel this authorization by signing, dating and writing CANCEL on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it; my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my health evaluation and/or treatment. Patient Name (Printed) of Birth Patient Signature Signature of the witness: : Guardian s signature and date (if patient is a minor and/or unable to sign for him/herself). Patient s Name (Printed) 8
9 Patient Questionnaire: Syeda N. Sultana, M.D. Patient s Name: Age: Marital Status: Occupation: Depressed Mood [ ] Decreased Appetite [ ] Anxiety [ ] Increased Appetite [ ] Lack of Interest [ ] Guilt [ ] Increased Sleep [ ] Social Withdrawal [ ] Hopelessness [ ] Suicidal Thoughts [ ] Homicidal Thoughts [ ] Self-Destructive Acts [ ] Poor Concentration [ ] Mood Swings [ ] Muscle Tension [ ] Panic Attacks [ ] Headaches [ ] Obsessions [ ] Stomachaches [ ] Rituals [ ] Muscle Pain [ ] Hallucinations [ ] Back Pain [ ] Delusions [ ] Trauma [ ] Nightmares [ ] Dissociation [ ] Gambling [ ] Lying [ ] Phobias [ ] Alcohol Abuse [ ] Drug Abuse [ ] Seizures [ ] Inattention [ ] Blackouts [ ] Distractibility [ ] Hyperactivity [ ] Explosive Temper [ ] Impulsivity [ ] Poor Concentration [ ] Bedwetting [ ] Soiling [ ] Learning Problems [ ] Delayed Development [ ] Mental Retardation [ ] Place of Employment: If a student, grade level: School: Lives with: Who referred you to us? Check all that apply: List all current medications and dosages with name of prescribing physician: Allergies: Medical illnesses: _ Are you on medical leave? (Y/N). If yes, explain:. Are you in counseling? (Y/N) List all psychiatric hospitalizations and dates: History of physical abuse (Y/N)? Do you currently use drugs/alcohol/opioids or cigarettes (Y/N)? History of legal problems (Y/N)? Where were you born? City, State, Country Parents divorced (Y/N)? History of drug/alcohol/opioid or cigarette use (Y/N)? If yes, how old were you? Are you on probation (Y/N) How many brothers: sisters:? Birth order? Where were you raised? Signature: : 9
Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900
PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip
More informationADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Ok to leave message? Yes No Work phone: Ok to leave message? Yes No Cell phone: Ok to leave message? Yes No Email:
More informationLAST 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
More informationDavid 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
More informationPatient Registration Please Print Patient Name Last First Middle
Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact
More informationBehavioral Health Consulting Services, LLC
www.bhcsct.org infohealth@bhcsct.org 46 West Avon Road 322 Main St. 530 Middlebury Road Suite 202 Suite 1-G Suite 103 B Avon, CT 06001 Willimantic, CT 06226 Middlebury, CT 06762 Office phone- 1-860-673-0145
More informationPATIENT 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
More informationPatient Information Form Trinity Wellness Center. Insurance Information
Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # -- -- Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student
More informationMichael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION
Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION PLEASE PRINT CLEARLY DATE NAME ADDRESS DX (OFFICE USE ONLY) CITY STATE ZIP OCCUPATION HOME PHONE EMAIL WORK PHONE CELLULAR
More informationAssociates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909
Parents Names (If Client is a Minor) Client Information Sheet Client s Last Name First M.I.. Social Security No. Date of Birth: Age Sex M / F Home Phone No.( ) Education Level: Marital Status: Home Address:
More informationTransitions 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
More informationIntake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:
Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:
More informationNEW PATIENT INFORMATION CONSENT AND AGREEMENT
NEW PATIENT INFORMATION CONSENT AND AGREEMENT PSYCHOLOGICAL SERVICES. Psychological services vary depending on the reason for referral. In all cases, the initial appointment is set up with the parents/guardians
More informationArrive 15 minutes before your scheduled appointment time.
Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist
More informationAtlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328
Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 An important part of the helping relationship is understanding the expectations of the relationship.
More informationDeclaration of Practices and Procedures
LOGAN MCILWAIN, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: (225) 387-2287 Fax: (225) 383-2722 Declaration of Practices and Procedures I am pleased
More informationSuzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398
Suzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398 Thank you for filling out this form. All information will be kept in strict confidence. Name Date Address
More informationPLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:
To Our New Patient: Our primary concern is providing you with excellent eye care. Your understanding of our policies and your cooperation with our procedures enables us to provide this care. Complete eye
More informationThe Center for ADHD, Inc.
Consent to Evaluate and Treat Date: Patient: Age: Date of Birth Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Work/Cell: Person(s) Responsible for Payment: Address
More informationPiedmont Psychiatric Services
Piedmont Psychiatric Services 2094 Woodruff Rd. Greenville, SC 29607 Tony R. Goodbar, MD Jeffrey K. Smith, MD Joseph A. Friddle, PA-C James M. Harbin, M.Ed., LPC Michael D. Smith, MA, LPC Albert C. Bennett,
More informationI authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat.
CENTER FOR ADHD, INC. AND R. TIMOTHY BROWN, M.D., LLC Consent to Evaluate and Treat Patient: Age: Date of Birth: Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Business/Cell
More informationChildren s Community Health Plan INTENSIVE IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE SERVICES ASSESSMENT AND RECOVERY / TREATMENT PLAN ATTACHMENT
Children s Community Health Plan INTENSIVE IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE SERVICES ASSESSMENT AND RECOVERY / TREATMENT PLAN ATTACHMENT Please fax with CCHP prior authorization form to 608-252-0853
More informationPATIENT 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
More information11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
More informationUPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth:
COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors UPDATE FORM 2011 Please fill out this form completely (front and back) Name: (First) (Last) (Middle
More informationVirginia South Psychiatric & Family Services
All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow
More informationADULT PATIENT INFORMATION BILLING PARTY IF OTHER THAN PATIENT INSURANCE
ADULT PATIENT INFORMATION Name DOB Address City State Zip Home Phone Cell Phone Work Marital Status: S M D W Sex: M F Social Security Number Place of Employment How Long? Referred by BILLING PARTY IF OTHER
More informationSPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)
Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC 27615 Mobile: 919-760-3068 Fax: 919-676-9946 Email: walker@carolinaperformance.net Couples
More informationPiedmont Psychiatric Services
Tony R. Goodbar, MD Jeffrey K. Smith, MD Joseph A. Friddle, PAC Piedmont Psychiatric Services 2094 Woodruff Rd. Greenville, SC 29607 James M. Harbin, M.Ed., LPC Michael D. Smith, MA, LPC Albert C. Bennett,
More informationOUTPATIENT SERVICES CONTRACT
OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions
More informationADULT MEDICAL SERVICES PC 6645 Main St. Suite A, Williamsville, NY 14221 (716) 276-8726 (Office) (716) 276-8730 (Fax)
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information
More informationJames A. Purvis, Ph.D. Psychotherapy Services Agreement
James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist
More informationComprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms,
Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms, PATIENT INFORMATION Last Name/ First Name/ M.I. Social Security Number: Date of Birth (MM/DD/YY):
More informationKeweenaw Holistic Family Medicine Patient Registration Form
Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend
More informationEllyn L. Turer, PsyD, PLLC 1320 19 th Street, NW Suite 202 Washington, DC 20036 Tel: 202-293-6463, ellyn-turer@hushmail.com
Date CLIENT INFORMATION Client Name Address City State Zip Code Primary Contact Ph # Cell Home Work Secondary Ph # Cell Home Work Email Address Do you text? Yes No Birth date Social Security Number Occupation
More informationPATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone #
Boguslaw Gluszak, MD Date: PATIENT INFORMATION Patients Last Name First MI SSN: DOB Age Sex: M F Address City State Zip Code Home Phone # Alt. Phone # Parents/Guardians: N/A Name of Primary Insurance:
More informationNew Perspective Counseling Services Child/Teen Intake Form
Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.
More informationMAT Disclosures & Consents 1 of 6. Authorization & Disclosure
MAT Disclosures & Consents 1 of 6 Authorization & Disclosure ***YOUR INSURANCE MAY NOT PAY FOR ROUTINE SCREENING*** *** APPROPRIATE SCREENING DIAGNOSES MUST BE PROVIDED WHEN INDICATED*** Urine Drug Test
More informationThe 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:
More informationREGISTRATION FORM (Please print)
REGISTRATION FORM (Please print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not so,
More informationCENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork
New Patient Paperwork NAME OF PATIENT ( ) MALE ( ) FEMALE ADDRESS APT CITY STATE ZIP HOME PHONE # CELL PHONE # DATE OF BIRTH AGE SOCIAL SECURITY # MARITAL STATUS E-MAIL ADDERSS OCCUPATION EMPLOYER EMPLOYER
More informationHorizon 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 informationREFERRAL INFORMATION CHILD, YOUTH AND FAMILY PROGRAM
Please Note the following information: WE DO NOT OFFER EMERGENCY OR CRISIS SERVICE Please print clearly and ensure contact information is correct. Complete all forms. We will contact the family to set
More informationPsychiatric Consultants of Atlanta, P.C. 1835 Savoy Drive Suite 101 Atlanta, Georgia 30341 Phone: 770-234-0981 Fax: 770-234-0252 www.pcatl.
Psychiatric Consultants of Atlanta, P.C. 1835 Savoy Drive Suite 101 Atlanta, Georgia 30341 Phone: 770-234-0981 Fax: 770-234-0252 www.pcatl.com CONTACT INFORMATION AND PERSONAL DATA Name: Date of Birth:
More informationMarian R. Zimmerman, Ph.D.
Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date
More informationGarland s Christian Counseling Center
Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave
More informationWake Forest Mind and Health, PLLC 501 North Main Street Wake Forest, NC 27587
Wake Forest Mind and Health, PLLC 501 rth Main Street Wake Forest, NC 27587 Katherine E. Walker, PhD, LPC, NCC, BCIA-C Jennifer Endries, MEd, LPC Licensed Professional Counselor Licensed Professional Counselor
More informationMosaic Arlington Counseling Center 817 W. Park Row Arlington, Texas 76013 Phone: (817) 929-3408 NEW CLIENT INFORMATION
NEW CLIENT INFORMATION (Please Print) / / Client Name M/ F of Birth Address City/State Zip Home ( ) Work ( ) Cell ( ) Email Address: (Circle One) Minor Single Married Divorced Separated Widow Living Together
More informationCalifornia Pain Consultants - PATIENT REGISTRATION FORM
Patient Information California Pain Consultants - PATIENT REGISTRATION FORM First name: Last name: Middle Initial: Address: City, State, Zip Home phone :( ) -Work phone: ( ) -_Cell: ( ) - Birth Date: Age:
More informationDate of Current Marriage/Separation: Highest Level of Education:
ADULT INTAKE FORM Name: Date: Social Security: Home Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: May we call you and leave messages at home? Yes No May we call you and leave messages
More informationPATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone
PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced
More informationWarner Family Counseling
Warner Family Counseling General Policies Insurance: I will file claims on your behalf, provided that I am an in-network contracted provider with your individual plan. Prior to our first meeting contact
More informationPediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (
Eye Consultants of Atlanta, P.C. Scottish Rite Office 5445 Meridian Mark Road, Suite 220, Atlanta, GA 30342 Phone: (404-255-2419) - Fax (404-255-3101) Zane Pollard, M.D. Marc F. Greenberg, M.D. Mark A.
More informationIMS 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
More informationMedical 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
More informationBORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP
BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP 9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com Welcome! Thank
More informationClient Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no
Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478
More information21031 Michigan Avenue Dearborn, MI 48124
21031 Michigan Avenue Dearborn, MI 48124 19725 Allen Rd #102 Brownstown, MI 48134 44633 Joy Rd #200 Canton, MI 48187 Phone: 313-277-6700 FAX: 313-277-2483 Date: Dear Patient: An appointment has been scheduled
More informationDr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax
Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments
More informationPATIENT TREATMENT AGREEMENT
PATIENT TREATMENT AGREEMENT Patient Name: : As a participant in buprenorphine treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment agreement as follows: I
More information8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078
Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd
More informationHow To Get A Medical Checkup
NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate
More informationPatient 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
More informationSingle Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
More informationOffice Policy & Procedures
Office Policy & Procedures Office hours are: Monday Thursday from 8am to 8pm, Friday from 8am to 6pm and Saturday/Sunday/Holidays open for sick visits only. Appointments are not scheduled ahead of time
More informationClient Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No
: Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas 76107 Client Intake Information Client Name: Street Address: City: State: ZIP:
More informationThank you for your cooperation.
DR. RICHARD P. TOWNSEND M.D. VERONICA DEAN FNP-C Family Nurse Practitioner LAURA GRUNDY FNP-BC Family Nurse Practitioner Dr. Richard Townsend is a third generation physician. He was educated in Canada
More informationNEW PATIENT INFORMATION
NEW PATIENT INFORMATION Date Patient Name Sex Age DOB / / Address City State Zip Phone Email Emergency Contact: Relationship to patient: Phone #(s) How did you hear about my practice? RESPONSIBLE PARTY
More informationNorth Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:
More informationWhen you arrive for your first appointment, please bring the following with you:
115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your
More informationConroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment.
Conroe Physician Associates Patient Consent Form Please Read and Sign I, undersigned, hereby consent to the following: Administration and performance of all treatments Administration of any needed anesthetics
More informationOK to leave Messages?
Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date
More informationADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012)
ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012) PATIENT REGISTRATION FORM & FINANCIAL PAYMENT POLICY Patient Info: Please print
More information5421 Riverbluff Parkway North Charleston, SC 29420 (843) 300-0440 counseling@riverbluff.org
Minor Child 5-12 years Client Information Packet Please take a moment to complete all of the following information. This information will assist us in getting to know you and what prompted you to seek
More informationStonebridge 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
More informationNew/Updated Patient Information
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
More informationSanta Fe Sage Counseling Center
Couple/Family Client Intake Date: Names: Partner/Parent/Child (circle one) Partner/Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Insurance ID #:
More informationJames H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc.
James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc. 89 Moraga Way, Suite B Tel: 925-285-2429 Orinda, CA 94563 Fax: 925-429-9259 Name
More informationSignature: Date: Witness:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Home Telephone:( ) Referred By: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone
More informationAmanda G. Johnson, LPC
Child Personal Information Child s Name: Date: Age: DOB: / / Gender: M F Race: Address: Apt: City: State: Zip Code: Father s Name: Date of Birth: / / Age Father s Occupation: Phone Number: Mother s Name:
More informationPatient or Guardian Signature
Co Payment Policy According to the regulations of individual insurance carriers, patients are responsible for paying co payments at the time of each office visit. PAYMENT POLICY FOR SERVICES RENDERED If
More informationLicense Number: Occupation:
P a g e 1 Today s Appt : Time: Physician: Patient s Name of Birth: Age: Address: Home Phone: Business Phone Cell Phone Sex Social Security: Marital Status License Number: Occupation: Who is your Primary
More informationSouthlake Psychiatry. Suboxone Contract
Suboxone Contract Thank you for considering Southlake Psychiatry for your Suboxone treatment. Opiate Addiction is a serious condition for which you may find relief with Suboxone treatment. In order to
More informationNEUROPSYCHOLOGY QUESTIONNAIRE. (Please fill this out prior to your appointment and bring it with you.) Name: Date of appointment: Home address:
NEUROPSYCHOLOGY QUESTIONNAIRE (Please fill this out prior to your appointment and bring it with you.) Name: Date of appointment: Date of birth: Age: _ Home address: _ Home phone: Cell phone: Work phone:
More informationNorth Bay Regional Health Centre
Addictions and Mental Health Division Programs Central Intake Referral Form The Central Intake Referral Form is used in the District of Nipissing by the North Bay Regional Health Centre s Addictions and
More informationWELCOME to New Jersey Spine and Pain Institute
WELCOME to New Jersey Spine and Pain Institute Our Commitment to You We will provide you with the most appropriate care in the most time efficient fashion. We will treat you with respect and professionalism.
More informationBOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES
BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established
More informationJerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006
Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006 CELL (937) 684-7746 PLEASE USE THIS NUMBER TO SCHEDULE OR CHANGE APPOINTMENTS INFORMED CONSENT FOR TREATMENT
More informationBEACON HEALTH STRATEGIES, LLC TELEHEALTH PROGRAM SPECIFICATION
BEACON HEALTH STRATEGIES, LLC TELEHEALTH PROGRAM SPECIFICATION Providers contracted for the telehealth service will be expected to comply with all requirements of the performance specifications. Additionally,
More informationAGREEMENT 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 informationReason(s) For Referral: Current medications:
1540 Sunday Drive Suite 200Raleigh, NC 27607 Office: 919-859-9040FAX: 919-859-9030 Name: Date Examined: Responsible Person: _ Birth Date: Address: Age: Sex: M F Marital Status: S M D W SSN: Home Phone:
More informationEmployed Full Time Student Part time student Patient s School Name / Employer School/Employer Address City State Zip
PATIENT INFORMATION DATE: Patient s Name Last First Middle Initial Patient s Address City State Zip Patient s Birth Date / / Male Female Age SS# Single Married Other May we call/leave message for appt.
More informationDeclaration of Practices and Procedures
Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722
More informationREHAB 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
More informationFaculty Group Practice Patient Demographic Form
Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred
More informationAdult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
More informationMIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS
More informationMental Disorders (Except initial PTSD and Eating Disorders) Examination
Mental Disorders (Except initial PTSD and Eating Disorders) Examination Name: Date of Exam: SSN: C-number: Place of Exam: The following health care providers can perform initial examinations for Mental
More informationPSYCHIATRIC INFORMATION: Currently in treatment? Yes No If no, what is barrier to treatment: Clinical Treatment Agency:
APPLICATION FOR CHILD AND YOUTH MENTAL HEALTH SUPPLEMENTARY SERVICES PROGRAM REQUESTED: Respite Services Supportive Intensive Home and Community-Based Case Management Case Management Services Waiver Referrals
More information