/ / Secondary Insurance Company: Insurance Holder s Name: Ins. Holder s Date of Birth:
|
|
|
- Adrian Montgomery
- 7 years ago
- Views:
Transcription
1 Welcome! Please print in the appropriate fields below regarding your information. If you do not know the requested information, please remember to bring that information with you upon your next visit. NEW PATIENT FORM: Please fill in the information Patient Name: Date of Birth: / / Primary Phone Number: ( ) Social Security Number: Sex: M F Marital Status: Cell Phone Number: ( ) Address Work Phone Number: ( ) Street Address: Preferred Language: City: Race: State, Zip Code: Ethnicity: Insurance Information: Please fill in the information below. PRIMARY Insurance Primary Insurance Company: Insurance Holder s Name: Ins. Holder s Date of Birth: Insurance Policy #: Insurance Group #: Does this Insurance need a referral? If so, provide the referral #: SECONDARY Insurance Secondary Insurance Company: Insurance Holder s Name: Ins. Holder s Date of Birth: Insurance Policy #: Insurance Group #: Does this Insurance need a referral? If so, provide the referral #: 1 of
2 Physician Contact: Doctors: Who is the physician who referred you to Retina Consultants, Ltd? Who is your primary care physician? Other doctors who are treating you? Emergency Contact Information: Someone we can contact in case of an emergency. City: Relation: 2 of
3 Basic Medical History: Please fill in the appropriate fields below. Allergies: Please list any drug, food, or other allergies below. Allergy: Reaction: Medications: Please list any medications you are currently taking below. Eye medications: Other Medications: Past Bodily Surgeries and Procedures: Please list any past surgeries below. Surgery/Procedure: Performed by (doctor): Date of Surgery/Procedure: Birth History: Please indicate your birth history below. Birth duration and weight: lbs. Any unusual circumstances? (premature, alcohol ingestion, oxygen therapy, birth trauma, etc.): oz. 3 of
4 Medical History: Please list any conditions, when they were diagnosed, and if they are controlled. Example: Type II Diabetes, diagnosed 1990, controlled with medication Condition, diagnosed/onset, mitigating factors: Family History: Please list if anyone in your family has had the following conditions: Amblyopia Blindness: Cataracts: Crossed eyes: Diabetic retinopathy: Glaucoma: Macular degeneration: Retinal detachment: Cancer: Diabetes: Heart disease: High blood pressure: Stroke: Other: Social History: Please answer the following questions below regarding your social history. Do you smoke? Y N Do you consume alcohol? Y N What is your occupation? Do you have any restrictions while driving? If so, please list below: 4 of
5 Review of Systems: Please list if you are currently dealing with any of these symptoms, chronic or otherwise: Constitutional Example: fevers, weight loss, etc. Eyes Ex: blurred vision, floaters, etc. Ear/nose/throat Ex: hearing or sinus problems, etc. Cardiovascular Ex: chest pain, irregular heartbeat, etc. Respiratory Ex: shortness of breath, wheezing, etc. Gastrointestinal Ex: abdominal pain, nausea, etc. Genitourinary Ex: blood in urine, discomfort, etc. Musculoskeletal Ex: joint pain, low back pain, etc. Integumentary skin/breast Ex: rashes, skin tumor, etc. Neurological Ex: numbness, weakness, etc. Psychiatric Ex: anxiety, depression, etc. Endocrine Ex: heat intolerance, thyroid problems, etc. Hematologic/lymphatic Ex: anemia, unusual bleeding, etc. Allergic/immunologic Ex: hives, seasonal allergies, etc. 5 of
6 Today: Please fill out the following information regarding your visit today if applicable. What is the main REASON for your visit today? Examples: Blurry vision in the right eye, poor vision in both eyes, dark spot in left eye, flashes of light, etc. When did it start? Examples: Started yesterday morning, started after skating accident, began late last night, began 3 years ago, etc. Has it worsened or gotten better since then, gradually? Immediately? Why? Examples: Suddenly worsened because of movement, gradually improves as day goes on, occasionally worsens throughout week, etc. What affects the visual problem? Examples: Worse at night, more floaters when head is shaken, better vision with more light, flashes of light show up when moving from light to dark room, etc. Do you have any pain associated with the visual problem? Examples: Sharp pain on sides of eyes, pain rated 3 of10, pulsing pain in the morning, etc. 6 of
7 Authorization to Inform and Bill Insurance, Responsibility of Payment I hereby authorize Retina Consultants, Ltd. to furnish information to insurance carriers and I authorize insurance benefits to be made to myself or on my behalf to Retina Consultants, Ltd for services rendered to my dependents or me. All professional services rendered are changed to the patient. Necessary forms will be completed to help expedite insurance carrier benefits. However the patient is responsible for all fees regardless of insurance coverage. I further understand that insurance coverage does not guarantee payment of services and that the patient/guardian/caregiver is responsible for payment of all fees owed to Retina Consultants, Ltd. non-payment for services rendered will result in discontinuation of services. X Signature of Patient or Legal Guardian Date Patient Consent for Use and Disclosure of Protected Health Information With my consent, Retina Consultants, Ltd. may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to Retina Consultants, Ltd. s tice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review and have been notified of the tice of Privacy Practices prior to signing this consent. Retina Consultants, Ltd. reserves the right to revise its tice of Privacy Practices at any time. A revised tice of Privacy Practices may be obtained by forwarding a written request to the Retina Consultants, Ltd. Privacy Officer at Retina Consultants, Ltd E. Dempster St., Ste. 400, Des Plaines, IL With my consent, Retina Consultants, Ltd. may call my home or other designated location and leave a message on voic or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders insurance items, and any call pertaining to my clinical care, including laboratory results among others. With my consent, Retina Consultants, Ltd. may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With my consent, Retina Consultants Ltd. may my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Retina Consultants, Ltd. restrict how it discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions but, if it does, it is bound by this agreement. By signing this form, I am consenting to Retina Consultants, Ltd. s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Retina Consultants, Ltd. may decline to provide treatment to me. X Signature of Patient or Legal Guardian Date Patient s Name Please print name of Legal Guardian if applicable 7 of
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
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
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:
TALLAHASSEE EYE CENTER
TALLAHASSEE EYE CENTER PATIENT INFORMATION Date: Name: Gender: M / F First MI Last Date of Birth: / / Address: City: State: ZIP: Phone Numbers: Home: Cellular: Work: E-Mail: SS#: - - What is the best way
New York Ophthalmology, P.C.
New York Ophthalmology, P.C. Dear Patient, Ophthalmology * PLEASE PRINT ON SINGLE SIDED, WHITE PAPER * Opthalmic Surgery Optometry * PLEASE USE BLACK INK ON ALL FORMS * Cornea External Disease Laser Vision
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: ( ) -
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
Medical Insurance and Vision Plans
Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction this portion of the examination determines the best lens correction
How to Remove a Social History Smoke?
AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:
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)
PATIENT INFORMATION FORM. Name: Address: City: State: Zip: Social Security Number: Telephone Numbers Home: Age: Sex: M / F Work: Email: Cell:
PATIENT INFORMATION FORM Name: Address: City: State: Zip: Social Security Number: Telephone Numbers DOB: Home: Age: Sex: M / F Work: Email: Cell: Marital Status: Single Married Spouse s Name: Widowed Divorced
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
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
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405
19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405 Welcome to our practice. We are happy that you selected us as your eye care provider and appreciate the opportunity
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
MEDICAL & OCULAR HISTORY QUESTIONAIRRE
MEDICAL & OCULAR HISTORY QUESTIONAIRRE Name: Date: Age: Preferred Pharmacy Name: Address: 1. Please describe briefly the main reason you are being examined today. 2. Do you have any of the following conditions
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
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com 1 Calvin E. Mein, MD 9480 Huebner Rd, Suite 310 (210) 615-1311 Moises A. Chica, MD San Antonio,
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork.
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork. So we may eliminate any potential waiting time, please fax the completed forms
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
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:
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
HISTORY OF PRESENT ILLNESS
d/b/a Guggino Eye Center 3115 W. Swann Ave., Tampa, FL 33609 (813) 879-7711 13904 N. Dale Mabry Hwy., Suite 200, Tampa, FL 33618 (813) 908-2020 3205 Physicians Way, Sebring, FL 33870 (863) 385-1544 HISTORY
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
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
PATIENT/PARENT/GUARDIAN SIGNATURE
PATIENT REGISTRATION PATIENT S NAME: SEX MALE FEMALE DOB: SOCIAL SECURITY #: CITY/STATE/ZIP: PHONE # GUARANTOR INFORMATION (if responsible party is not the patient) MOTHER S NAME: DOB: SS#: CITY/STATE/ZIP:
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527 Patient Information Name First Middle Last Address City State Zip Phone Other Contact Email Social Security # DOB
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:
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
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
Dear Patient, Thank you for choosing Georgia Eye Associates. We strive to provide you with state-of-the-art eye care in comfortable surroundings.
Donald E. Poland, M.D. Kris F. Gillian, M.D. Dickie McMullan, M.D. Frank L. Winski, O.D. Brian A. Kahn, O.D. Brigette Rabitsch, O.D. Dear Patient, Thank you for choosing Georgia Eye Associates. We strive
Welcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear
Welcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear If you are a new patient to our practice and would like to complete new patient forms before you arrive, please print
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE WELCOME TO OUR OFFICE Patient Information Insurance Information Today s Date Last First MI Street City State Zip Code Home Phone Work Phone Cell Phone Email Address How do you prefer
General Medical Questionnaire
JONATHAN S LYONS MD, THOMAS H YAU MD, LLC ROBERT P FRIEDLAENDER MD ARUSHA GUPTA MD EYE PHYSICIANS AND SURGEONS 8630 Fenton Street, Suite 514 Silver Spring MD 20910 PATIENT INFORMATION FORM (PLEASE CIRCLE)
MEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day
MEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day PATIENT REGISTRATION CONFIDENTIAL PLEASE COMPLETELY PRINT THE FOLLOWING AND SIGN BELOW PATIENT INFORMATION
Patient Demographic Sheet
Patient Demographic Sheet Patient Name: Date of Birth: Address: City, State, Zip Code: Home Phone: Cell Phone: Work Phone: E-Mail: Sex: Male Female Marital Status: Married Single Other Occupation: Employer:
Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
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
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834 Dear New Patient: Welcome to Associates in Pediatric and Adult Urology, PA, a
THE EYE INSTITUTE. Dear Patient:
THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0464 Eye Institute North, LLC 5677 Berkshire Valley Rd. Oak Ridge, NJ 07438 p. 973-208-0600
11120 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
THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465
THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465 Dear Patient: Welcome to the Eye Institute. Our mission is to provide you with the highest
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:
Cutting Edge Eye Care
Cutting Edge Eye Care The Optos Daytona provides an unequaled 200 degree view of your retina in a single image. This view gives our doctors the opportunity to identify and follow peripheral retinal pathology
Orthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
CORONADO EYE ASSOCIATES GLENN B. COOK, M.D., PhD 801 ORANGE AVENUE, STE. 204 - CORONADO, CA 92118 619.437-4406 FAX 619.522-7983
Dear Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible. Enclosed is your patient information sheet and medical history questionnaire. Please
Please Print. Patient Name Last First Middle. Address Street Apt # City State Zip. Date of Birth Gender. Home Phone Cell Phone
Please Print Patient Name Last First Middle Address Street Apt # City State Zip Date of Birth Gender Home Phone Cell Phone Work Phone Social Security# E-mail Occupation Employer Spouse s Name Phone Referred
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)
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
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
Eye Care of Delaware Patient Health Questionnaire
Eye Care of Delaware Patient Health Questionnaire Name: Date of birth: Referred by: Eye doctor: Family doctor: Pharmacy name: Phone #: Pharmacy location: Reason for today's visit (signs/symptoms): When
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER
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
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register
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:
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.
Dear Patient, We look forward to seeing you.
Dear Patient, Welcome to Mosier Eye Center! We appreciate your selection of our office and we look forward to serving you for all your eye care needs. This packet was created to provide you with some valuable
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
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 #: /
Westoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
The Dermatology & Laser Group of Irvine, A.M.C. 16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115
16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115 (Please Print) Today s Date / / PATIENT INFORMATION Name Last First M.I. Maiden Name: SS# Email: Mr. Ms.
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
DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION
DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
E/M LEVEL WORKSHEET. Category. Subcategory (if applicable) (new/established, etc.)
E/M LEVEL WORKSHEET STEP 1 : IDENTIFY THE CATEGORY AND SUBCATEGORY OF SERVICE Carefully read the documentation. Using the Table of Contents, identify the appropriate category/subcategory. Category Subcategory
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
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
Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 info@benjamineye.com www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
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
RETINA CARE CENTER, P.C. PATIENT INFORMATION
RETINA CARE CENTER, P.C. JONATHAN M. BAROFSKY, M.D., F.A.C.S. Parkway Seventy Plaza 1255 Route 70, Suite 31N Lakewood, New Jersey 08701 PHONE (732)905 0004 FAX (732)905 3868 PATIENT INFORMATION Welcome
Agnes Ju Chang, M.D., F.A.A.D.
Agnes Ju Chang, M.D., F.A.A.D. Dear Valued Patient: Thank you for choosing Integrated Dermatology of K Street, the office of board certified dermatologists, Dr. Agnes Ju Chang, Dr. David A. Lee, Allison
Patient Demographics Sheet
Patient Demographics Sheet PLEASE PROVIDE YOUR PHARMACY INFORMATION BELOW: PREFERRED PHARMACY: PHARMACY LOCATION: PHARMACY PHONE NUMBER: FOR OFFICE USE ONLY Dr. Goldblatt Dr. Brown Last Name: First Name:
Electronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
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
Annual Eye Health Exam Eye Care Associates of Princeton DATE :
Annual Eye Health Exam Eye Care Associates of Princeton DATE : First Name: Last Name: Male/Female (circle) Date of Birth: Age: _ Employer: Occupation: Address: City: State: Zip: Cell Phone Number: May
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
Orthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible.
PAUL L. TREGER, M.D. RANDALL CONRAD, O.D. GLENN B. COOK, M.D., PhD TARA BROWN, M.D. 7877 PARKWAY DRIVE SUITE 100 - LA MESA, CA 91942 619.286.3711 FAX 619.286.2184 Dear Please allow us to welcome you to
We appreciate your selection of our office for your eye care.
Howard H. Tessler, M.D. General Ophthalmology Uveitis External Disease Cornea Nancy A. Hamming, M.D. Pediatric Ophthalmology & Strabismus Daniel J. Green, M.D., Ph.D. General Ophthalmology Glaucoma Rachael
PATIENT DEMOGRAPHIC SHEET
Patient Information PATIENT DEMOGRAPHIC SHEET Last Name First Name MI of Birth Age Social Security Number Married Widowed Single Other: Marital Status Occupation/Retired Employer English Spanish Mail Phone
REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
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
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net
360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first appointment at our office on
WELCOME TO COPPELL VISION CENTER
WELCOME TO COPPELL VISION CENTER Please Print Name Address Sex: Male Female City/State/Zip Age Home Phone of Birth Alternate Phone SSN# Profession Employed By Responsible Party Address and Phone Number
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
North 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:
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
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown)
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown) Patient Name: Date of Birth Mailing Address: City: State Zip: Apt/Ste/Unit/Bldg Primary Number: