Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician Dr Grewe Dr Florek
|
|
|
- Daniela Gibson
- 7 years ago
- Views:
Transcription
1 Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician Dr Grewe Dr Florek Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and thank you for choosing us to participate in your health care. Because you are important and deserve quality time with your doctor, please arrive 40 minutes prior to your scheduled appt to complete registration process and visit with a nurse. Additionally, we ask that you bring all medications you are currently taking, including supplements and over-the-counter medications, in the original bottles, so that they charted correctly upon your initial visit. Patient history: Please request the chart notes from your last visit with your primary care physician and history of specialty care including labs and X-rays (EKG, echocardiograms, and cardiac studies) and information on heart surgeries, catheters or other procedures. Patient history information should be faxed to the clinic as soon as possible. Please see the enclosed information regarding your first appointment. We request that you refrain from wearing perfumes or colognes, as we see many patients who are susceptible to allergic reactions to scents. Please bring the following to your appointment: Photo ID Medical insurance card Completed enclosed forms All current medications, in the original bottles If you have any questions, please call us at We look forward to seeing you soon. Providers: Kathy Grewe, M.D., Robert Florek, M.D.
2 Columbia Gorge Heart Clinic 1108 June St. Hood River, OR fax History form: Please fill out your medical history as completely as possible. Medications: Please bring in all your current medications in the original bottles. Record release form: If you are transferring from another care provider, please request your records be transferred to your new doctor before to your appointment. You will find this form, Authorization for Release of Medical Records, in your packet. If you need a copy of your lab results, you can sign a two-year release of records in your physician s office. Cancellation policy: We ask that you contact our office at least 24 hours before to your scheduled appointment if you need to cancel or reschedule. This allows appointments for other patients. Before your appointments: Please arrive 40 minutes before your scheduled appointment to allow time for registration. Remember to transfer your medical records from your previous provider. Notice: If you arrive more than 10 minutes past your scheduled appointment time, you may be asked to reschedule your appointment. Billing Questions: or
3 Today's Date / / Last Name First Name Middle Date of Birth / / CHIEF COMPLAINT - Briefly describe the main reason for your visit today. Have you been diagnosed with? (Please circle all that apply) Diabetes High Blood Pressure High Cholesterol Are you a current or former cigarette smoker? Current Former GENERAL HEALTH AND HABITS COLUMBIA GORGE HEART CLINIC - PATIENT HISTORY FORM EXERCISE Do you exercise regularly? Yes No How long have you exercised on a regular basis? Years Type Of exercise's) How Often? days/week,for Minutes. SMOKING Do you smoke? Yes Never Quit How many per day? How many years? What do you smoke? Cigarettes Pipe Cigars Other (specify) If you no longer smoke, when did you quit? If you no longer smoke, how long did you smoke and how heavily? ALCOHOL/BEVERAGES Do you drink alcohol? Yes No If yes, estimate the amount of drinks/beers: Per day Per week Did you formerly drink alcohol but have permanently stopped? Yes No Estimate the amount of caffeinated beverages (coffee, tea,cola) you drink per day glasses, cups, cans SOCIAL HISTORY What is your marital status If married, for how long? Do you have any children? Yes No If yes, how many? Are you currently employed? Yes No What is your occupation? If no longer employed or retired, what was your occupation? MEDICATIONS Are you allergic to any medications, Iodine, or shellfish? Yes No If yes, please list the name and the reaction Nursing staff must review your medications, vitamins and supplements at your appointment. Please bring all of your current medication bottles with you for accuracy. Reviewed by : Signature of Physician Date
4 PAST MEDICAL AND SURGICAL HISTORY List all surgeries that you have had, date and hospital if known. Operation Hospital and City Date List all hospitalizations not related to surgical procedures. Do not include childbirth. Reason for Hospitalization Hospital and City Date Have you ever had sedation or anesthesia before? If yes, list any problems? Have you ever had IV contrast before? If yes, list any problems? FAMILY HEALTH: Specifically, any direct blood relative ( grandparents, mother, father, sister, brother) Have any of the above family members been diagnosed with heart disease? Have any of the above family members been diagnosed with diabetes? Have any of the above family members been diagnosed with disease of the arteries or veins? Have any of the above family members been diagnosed with a TIA or stroke? Have any of the above family members been diagnosed with high blood pressure? Have any of the above family members been diagnosed with high cholesterol? Reviewed by : Signature of Physician Date
5 PROVIDENCE HEART CLINIC - SYSTEM REVIEW FORM Do you NOW have any problems related to the following systems? Circle Yes or No CARDIOVASCULAR (HEART) GASTROINTESTINAL Chest Pain Poor appetite Heart trouble Trouble swallowing Heart attack Heartburn Angina pectoris Nausea or vomiting High cholesterol Abdominal pain High blood pressure Constipation Fainting Diarrhea Racing of heart GI bleeding Rheumatic fever Other Heart failure Abnormal EKG CONSTITUTIONAL SYMPTOMS Swelling of ankles Fever Leg cramps Chills Headache RESPIRATORY (LUNGS) Weight gain Wheezing Weight loss Frequent cough Other Shortness of breath Disruptive Snoring EYES Breathing Pauses Blurred vision Excessive Daytime Sleepiness Double vision Other Pain Other ENDOCRINE Hormone problems ALLERGIC/IMMUNOLOGIC Thyroid disease Hay fever Diabetes Drug allergies Osteoporosis Other Other NEUROLOGICAL GENITOURINARY Stroke Urine retention TIA - Mini stroke Painful urination Dizzy spells Urinary frequency Numbness/Tingling Other Other HEMATOLOGICAL/LYMPHATIC EARS/NOSE/THROAT/MOUTH Swollen glands Ear infection Blood clotting problem Sore throat Other Sinus problems Other INTEGUMENTARY (SKIN) Skin rash MUSCULOSKELETAL Other Joint pain Neck pain PSYCHIATRIC Back pain Memory Loss or confusion Other Depression Sleep Problems Other Reviewed by : Signature of Physician Date
6 Others Involved in Your Health Care This office requires a signed release to give any information regarding appointments, test results, health status, etc. to others. Anyone not listed on this form will not be given any information without a separate, specific release signed by the patient or legal representative. Please note: Patients are no longer considered minors after age 17. If a patient over the age of 17 wishes to release information to a parent or guardian, they must include the name and relationship of that person on this form. Information will not automatically be given because a patient resides with his or her parent(s) or guardian(s). Medical information is to be released to: Name Relationship Phone number Patient name [Print] Authorized signature Legal representative if not patient [Print] Date of birth Today s date Relationship MR#
7 Authorization for Release of Medical Records Patient s Name: First Middle Last Date of Birth: / / Social Security Number: PERMISSION IS HEREBY GRANTED FOR RELEASE OF INFORMATION FROM: TO: Name (Medical Provider holding records): Address: Name: Phone # Address: Fax # The purpose of the release is: Diagnostic Evaluation Reimbursement Follow-Up Care Legal Other The following information may be released: Clinical notes (Re: ) Laboratory Reports ( LAST 2 YEARS) Immunization Records Medication Records X-Ray Reports Other: EKG S, PATHOLOGY REPORTS, SPECIAL STUDIES, SPECIALISTS CONSULTS, HOSPITAL RECORDS INCLUDING ER VISITS, ADMITS, H&P S, IN PT. CONSULTS, SURGERY/PROCEDURE REPORTS, AND DISCHARGE SUMMARIES (LAST six MONTHS ONLY) Information may be released for dates of service from SEE ABOVE through SEE ABOVE This authorization expires six months from the date signed or: (specified expiration date) I have read the above and fully understand its contents. I have asked questions about anything that was not clear to me and I am satisfied with the answers I have received. (Signature of patient or representative) Relationship (if signed by representative) Date Signed Witness (optional) Driver s License/Identification I do /do not specifically consent to transmission of my medical records via a facsimile (fax) machine. I recognize that the information disclosed may contain drug/alcohol information that is protected by Federal and State law. I specifically consent to disclosure of such information Signature Date Signature Date I recognize that the information disclosed may contain mental health information that is protected by Federal and State Law. I specifically consent to disclosure of such information I recognize that the information disclosed may contain information regarding sexually transmitted diseases or HIV / AIDS testing information. I specifically consent to disclosure of such information Signature Date Signature Date This authorization may be revoked at any time unless prior action has been taken as a result of this form. Records obtained as authorized by this consent for information release will be maintained in accordance with Federal confidentiality regulations (Title 42 of the Federal Register) which prohibits re-disclosure. Medical Record #
8 Providence Prescription Refill Policy Columbia Gorge Heart Clinic 1108 June St. Hood River, OR fax Please request all prescription refills through your pharmacy: - Your pharmacy s phone number and your prescription number should be on your prescription bottle. - Call your pharmacy even if you have no refills remaining. Your pharmacy will contact your doctor for authorization. - If you are changing pharmacies, your new pharmacy can contact your previous pharmacy and transfer your existing prescriptions. Your new pharmacy will contact our office if refills are needed. Call your doctor s office for a refill only if: - Your prescription needs to be picked up in person. - You have a question about your medication. Please allow at least 72 hours to approve your refill request, as our refills are processed by a central refill service in Portland.
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
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
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
PATIENT 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
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
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
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:
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
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
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
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
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.)
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
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:
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
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:
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:
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:
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
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.
Welcome to Denver Arthritis Clinic!
Welcome to Denver Arthritis Clinic! We would like to introduce your to our DAC ehealth Portal with the convenience of 24-hour-a-day access. DAC ehealth Portal is a unique personalized service that allows
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
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
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:
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
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
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
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
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
PLEASE PRINT LEGIBLY
Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full
New England Pain Management Consultants At New England Baptist Hospital
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
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
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.
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 #: /
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
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
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:
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
Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine
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
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:
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
Hello, Please note: The following information will be needed at your appointment:
Hello, You are receiving this mailing because you or a family member have an upcoming appointment at the Albany Medical Center s Neurology Group as noted above. Our goal is to provide you with the best
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
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
LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS
PLEASE PRINT PATIENT LAST NAME: FIRST NAME DATE OF BIRTH: / / AGE: ADDRESS: APT CITY STATE ZIP HOME PHONE # CELL PHONE # WORK PHONE # SEX M F MARITAL STATUS DRIVER S LICENSE # SOCIAL SECURITY # - - EMPLOYER
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
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
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:
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,
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER:
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
PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION
PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL
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
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: ( ) -
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
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:
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
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
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
How To Get A Medical Checkup From A Doctor
Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number:
VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions
18 HEALY DR. WINSTON SALEM, NC 710 PH. 6-768-50 FAX- 768-19 Scott W. Baker, MD Patient Instructions 1. Bring a list of all regular medications and dosages.. Bring your insurance card and all necessary
PEDIATRIC MEDICAL HISTORY FORM
Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other
Community Internal Medicine of Athens 1500 Oglethorpe Avenue Suite 200D Athens, GA 30606 Phone: (706) 389-3875 Fax: (706) 389-3876
Please Fill Out Completely: Community Internal Medicine of Athens Phone: (706) 389-3875 Fax: (706) 389-3876 Patient s Last Name First Name MI Social Security Number Date of Birth Age Gender Race Marital
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
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.
Patient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip:
Welcome to Avenstar Pain Specialists! Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best
NORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
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
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:
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
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION Last Name First Name MI Mailing Address City Zip code Home Phone
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
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
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:
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(((((((()
Medical History PHARMACY INFORMATION. List Drug Allergies and Nature of Allergic Reaction: List Past and Current Medical Conditions:
PHARMACY INFORMATION Medical History Pharmacy Name: Phone #: Address: City: List Drug Allergies and Nature of Allergic Reaction: List Past and Current Medical Conditions: List Past Surgeries: List Medications:
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
Financial/Office Policy Brandon Family Medical Care, P.A. 414 West Robertson Street Brandon, Florida 33511 (813) 684-5255
Brandon B Family MEDICAL CARE Financial/Office Policy The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make
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.
FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA
PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )
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
(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Today s Date:
Page 1 of 5 (Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Age: What is the main reason for today s visit? Today s Date: Who referred you to
Referrals It is your responsibility to bring your referral if required. Failure to do so may result in cancellation of your appointment.
Welcome to Capital Endocrinology! We are happy to have you as a patient in our practice. Please take note of the following policies. Following these policies will help in making your visit as efficient
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
1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
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
North Carolina Orthopaedic Clinic Patient Registration Form
North Carolina Orthopaedic Clinic Patient Registration Form FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY PATIENT INFORMATION NAME: BIRTHDATE: AGE: TODAY S DATE: SOCIAL SECURITY
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
To make your Annual Wellness Visit as helpful as possible, we ask that you do the following:
Aspen Medical Group Crista Keller, M.D. Megan Press, M.D. Katherine Johnson, NP-C Susan Esmond, PA-C E. Kendrick Lane, PA-C To our valued Medicare Patients, Medicare will now be covering a free annual
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 HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
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.
TENNESSEE NEUROLOGY SPECIALISTS AT RIVER PARK HOSPITAL. E. Frank Lafranchise, M.D.
TENNESSEE NEUROLOGY SPECIALISTS AT RIVER PARK HOSPITAL E. Frank Lafranchise, M.D. River Park Hospital 1589 Sparta Rd Ste. 205 McMinnville, TN 37110 Phone: (615) 383-8575 Fax: (978) 701-6019 IMPORTANT-
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?
Patient Questionnaire for Men
Patient Questionnaire for Men Please fill out the following questionnaire to the best of your ability prior to your first appointment. Your physical therapist will review your responses during your initial
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
CITY STATE ZIP CITY STATE ZIP COUNTY USA OTHER PATIENT S CONTACT INFORMATION HOME PHONE # DAY PHONE # ALTERNATE PHONE E-MAIL ADDRESS
35 Casa Street Suite 130 San Luis Obispo, CA. 93405 P: 805-595-1808 F: 805-595-1815 Patient Information Please provide us with your insurance and valid ID PATIENT S INFORMATION NAME (Last, First, Middle)