How To Get A Medical Insurance Plan From A Doctor
|
|
- Suzanna McBride
- 3 years ago
- Views:
Transcription
1 PATIENT DEMOGRAPHICS SHEET Patient Name: Parent/Legal Guardian Name: Date of Birth: Phone: Address: CITY STATE ZIP Social Security Number: Patient Phone: Sex: M F Home Cell Business Okay to leave detailed message with medical information? YES NO (Initial) Preferred Appointment Confirmation: Text Message Phone Call Employer: Work Phone: Primary Care Doctor (First & Last name): Primary Care Doctor s Phone: Who referred you to our practice: Primary Insurance Company: Self (If self insured, please only complete policy number and group number) Insured s Name: Relationship to Patient: Insured s SSN: DOB: Sex: M F Insured s Address: Insured s Phone Number: Policy Number: Employer: Group Number: Secondary Insurance Company: *Please inform front desk if you have a Secondary Insurance Policy Ethnic Background (optional): Race: Emergency Contact Name: Relationship: Preferred Language: Phone:
2 HIPAA AUTHORIZATION FORM Patient Name: Social Security #: Any physician, staff, employee or representative of Riverside Dermatology & Aesthetic Center, P.C. has my permission to discuss my account and medical conditions which may include symptoms, treatments, diagnosis, test results, medications or any other type of protected health information with the following persons in order to facilitate and coordinate my care, treatment, and payment: I understand that authorizing the release of my information to the above individual(s) is voluntary and does not affect my access to treatment. I can refuse to sign this form. I can revoke it by writing to Riverside Dermatology & Aesthetic Center, P.C. or completing a new form at any time. This authorization will remain in effect until I change or revoke it. I understand that if information is shared with the above individuals it may be subject to redisclosure by the individual(s). Patient s Printed Name Signature Date Legal Guardian/ Patient Signature Date Representative Printed Name Copy given to patient
3 INFORMED CONSENT FOR MEDICAL PHOTOGRAPHY Photographs are a necessary part of the patient s personal and permanent medical record. Photographs are used to identify patients, prevent patient fraud, identify lesion and biopsy locations, follow suspicious lesions over time, and provide a complete and objective description of a lesion and location. Photography is a valuable tool that is utilized by this medical practice to enhance the practice of medicine and improve patient care. It also reduces the risk of incorrect lesion or site removal and improves the efficiency and accuracy of the staff and providers. I understand that any photographs taken of me may be placed in my medical record for future treatment, electronically ed to my referring, treating, or consulting health professional, used by health professionals for education and training, and used in paper or electronic health publications. I understand that if a photograph of my skin lesion or condition is published in marketing materials or medical journals that it will be a non-identifiable photograph, and that my privacy will in no way have been compromised. By signing below, I confirm that I understand this consent form, have had any questions about medical photography answered, and am agreeing to have my photograph taken in the office and stored on their digital devices. Patient s Printed Name Signature Date Legal Guardian/ Patient Signature Date Representative Printed Name Witness Printed Name Witness Signature Date
4 PRIVACY NOTICE CONSENT CONSENTS, RELEASES, & ACKNOWLEDGMENTS Our Notice of Privacy Practices provides you with information about how we use and disclose protected health information about you. By signing below, you acknowledge that you have received a copy of our Notice of Privacy Practices. A copy is also posted in our waiting room for your convenience. PHYSICIAN ASSISTANT CONSENT GENERAL RELEASE This office utilizes the services and practice of a Certified Physician Assistant. The level of practice has been approved by the Georgia State Board of Medical Examiners. The Physician Assistant is under the supervision of the Physician, and is in good standing with the National Commission on Certification of Physician Assistants. Your signature on this page acknowledges that you are in agreement with being treated by a Physician Assistant. INFORMATION RELEASE I authorize the release and disclosure of any and all of my medical and treatment records or reports to any other health care provider who may be of assistance, in the opinion of Riverside Dermatology & Aesthetic Center, and/or for assisting in any reimbursement of medical benefits to which patient may be entitled. I further authorize and request that insurance payments be made directly to Riverside Dermatology & Aesthetic Center should they elect to receive such payment. This is a direct assignment of my rights and benefits under this policy. FINANCIAL RESPONSIBILITY ACKNOWLEDGMENT I acknowledge full financial responsibility for services rendered by Riverside Dermatology & Aesthetic Center. I understand that payment of charges incurred is due at the time of services unless other definite financial arrangements have been made prior to treatment. I agree to pay all reasonable attorney fees and collection costs in the event of default of payment of my charges. I have read and fully understand and agree to the above Consent of Treatment, Financial Responsibility, Release of Medical Information, and Insurance Authorization. Patient s Printed Name Signature Date
5 Name: DOB: MEDICAL INTAKE SHEET Social Security Number: Date: Preferred Pharmacy Name: Pharmacy Phone Number or Location: Primary Care Doctor (first & last name): Past Medical History: Please check if you have or have ever had any of the following. Anxiety Colon Cancer Hepatitis Lung Cancer Arthritis Coronary Artery Disease High Blood Pressure Lymphoma Asthma Depression HIV / AIDS Prostate Cancer Atrial Fibrillation Diabetes High Cholesterol Radiation Treatments Bone Marrow Transplant End Stage Kidney Disease Hyperthyroidism Seizures Benign Prostate Enlargement GERD / IBS Hypothyroidism Stroke Breast Cancer Hearing Loss Leukemia NONE OF THE ABOVE Please list any other medical problems: Please list all previous surgeries: Skin Disease History: Please check if you have or have ever had any of the following. Acne Blistering Sunburn Flaking/ Itching Scalp Precancerous Moles Actinic Keratoses Dry Skin Hay Fever/Allergies Psoriasis Asthma Eczema Poison Ivy Skin Cancer Unkown Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma (list all affected & relationship) OTHER: NONE OF THE ABOVE Do you wear sunscreen? Yes No If yes, what SPF? Tanning Bed History: Never used Formerly used, but no longer use Currently use Please list (or attach) all your vitamins, supplements, and current medications (over the counter and prescription), and provide us with an updated list each visit: List any medication, food, or environmental allergies:
6 Social History: Do you currently smoke? Yes No Packs per day? for years Have you ever smoked? Yes No Packs per day? for years Cautions in Medical History: Please check all that apply. Artificial Joints (Joint Replacements) in past 2 years Artificial Heart Valve Coronary Artery Disease Planning Pregnancy Allergic to Adhesive Defibrillator Pregnant Allergic to Latex High Blood Pressure Pre-medicate prior to procedures Allergic to Lidocaine HIV / AIDS Prior Chemotherapy Allergic to Topical Antibiotics Low Blood Count Rapid Heart Beat with Epinephrine Blood Thinner Use Pacemaker Use Home Oxygen NONE OF THE ABOVE Family Medical History: Please check all that apply. Skin Cancer Unkown Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma (list all affected & relationship) Psoriasis Eczema Seasonal Allergies Autoimmune Disease Lupus Thyroid Problems Asthma NONE OF THE ABOVE If your appointment concerns Acne, please check if you have had either of the following: Scarring Acne Isotretinoin (Accutane) Use 1. What is your reason for today s visit? TODAY S VISIT 2. Do you need any refills on medications or products? Yes / No If yes, which ones? 3. Have you had any major health changes since your last visit? Yes / No If yes, please explain: *Fill out information below if applicable* 4. How long have you had the problem you stated in #1? 5. What location(s) of your body is/are affected? 6. What symptom(s) do you have? i.e. itching, hurting, bleeding 7. Does anything make this problem worse? 8. Does anything make this problem better? 9. How does this affect your life? 10. Have you been evaluated for this problem before? Yes / No If so, what diagnosis was given? 11. Did you receive any treatment? Yes / No If yes, what was it? 12. Is there anyone else in your family with similar symptoms? Yes / No
Calais Dermatology Associates
Calais Dermatology Associates Please present ALL insurance cards to the receptionist. If patient is a minor, and you are not the legal guardian, please ask receptionist for minor paperwork. Patient Information:
More informationAUBURN DERMATOLOGY PATIENT DEMOGRAPHIC (Please print legibly)
AUBURN DERMATOLOGY PATIENT DEMOGRAPHIC (Please print legibly) Patient Legal Name: DOB: M/F Home Phone: Work Phone: Cell Phone: Mailing Address: City: State: Zip: Preferred Email: Married: Single: Widowed:
More informationPATIENT REGISTRATION
PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital
More informationNew Patient Information
New Patient Information LAST FIRST NAME NAME M.I. DATE OF SOC. MARITAL BIRTH SEC. SEX STATUS PRIMARY ADDRESS PHONE CELL CITY STATE ZIP PHONE WORK EMPLOYER PHONE REFERRING/ YOUR PRIMARY PHYSICIAN E-MAIL
More informationSan Luis Dermatology & Laser Clinic, Inc.
San Luis Dermatology & Laser Clinic, Inc. Patient Name: Pharmacy Name: LOCATION Health History Intake Form The federal government has defined a complete electronic medical record (EMR) or electronic health
More informationWelcome. Carlos Paz, M.D., Ph.D. Dear Patient,
Welcome Dear Patient, We are delighted to welcome you to Fresno Dermatology Specialists, the office of Dr. Carlos Paz. This letter contains answers to some of the most commonly asked questions by patients
More informationPATIENT INFORMATION. Name: First Name Initial Last Name Nickname
PATIENT INFORMATION Name: First Name Initial Last Name Nickname Date of Birth: / / Sex: Male/Female Social Security # - - MM DD YY Marital Status: Single Married Divorced/Separated Widowed Address: Street
More informationPATIENT INFORMATION. Office Location:
Date: PATIENT NAME (Last, First M.I.): PATIENT INFORMATION (Please complete all sections) Office Location: DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
More informationAdvanced Eye Care, SC Patient Registration Form
Advanced Eye Care, SC Patient Registration Form (Please print and complete all entries.) Patient Name (First-MI-Last) Date of Birth Age Circle Marital Status Single Married Parent/Guardian (if patient
More informationAgnes 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
More informationRALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
More informationRace: Caucasian American Indian or Alaska Native Asian African American Native Hawaiian or Other Pacific Islander
NORTH DALLAS DERMATOLOGY ASSOCIATES DEMOGRAPHIC INFORMATION EMA INTAKE FORM PAGE 1 NAME: Female Male DOB: / / Age: Last First Race: Caucasian American Indian or Alaska Native Asian African American Native
More informationStanislaw Facial Plastic Surgery Center LLC Paul Stanislaw Jr., M.D.
Patient Information Stanislaw Facial Plastic Surgery Center LLC Paul Stanislaw Jr., M.D. Patient Name Date of Birth Age Address Marital Status Sex Address Home ( ) City State Zip Cell ( ) Employer Work
More informationOMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -
More informationNOTICE 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
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 informationPATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Email Address:
NEW HAMPSHIRE GASTROENTEROLOGY, INC. 9 Washington Place, Suite 204, Bedford, NH 03110 Office: 603-625-5744 Fax: 603-606-3049 ** Please return this form completed ASAP** PATIENT INFORMATION Name: DOB: DATE:
More informationWho to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -
4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)
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 information! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER
More informationJaworski Physical Therapy, Inc. Private Health Insurance. Worker s Compensation (complete the following)
Jaworski Physical Therapy, Inc. Patient Name: Date: Private Health Insurance Name of Private Health Insurance: ID#: Group#: Cardholder Name: Cardholder Date of Birth: Relationship to Patient: Phone: Address
More informationReferring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
More informationSOUTH PALM CARDIOVASCULAR ASSOCIATES, INC. CHARLES L. HARRING, M.D. NEW PATIENT INFORMATION FORM. Patient Name: Home Address:
NEW PATIENT INFORMATION FORM Today s Date: Referred by: Patient Name: (First) (Last) Date of Birth: Gender: M / F SSN: Home Address: Home Phone (Area Code & No.): ( ) - Cell Phone: ( ) - Secondary Address
More informationHow did you hear about our services? (Check ONE only)
Name: of Visit: Is your visit a MEDICAL or COSMETIC visit? (Check one) How did you hear about our services? (Check ONE only) 1. Newspaper Ad Name of Newspaper: 2. Internet via: Banner Ad Search via pdskin.com
More informationDouglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics Patient s Name Birthdate Who referred you to this office? Social Security # Address City ST ZIP Home Phone Work Phone Ext Cell Phone
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 Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
More informationWelcome 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:
More informationWilliam A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C
275 Collier Road NW Suite 470 Atlanta, GA 30309 William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C www.atlantabreastcare.com Phone:
More informationHow To Write A Medical History Questionnaire For An Aransas Plastic Surgery
Arkansas Plastic Surgery O David H. Bauer, M.D. O Gary E. Talbert, M.D. Appointment Date Patient Information INFORMATION FOR CASE HISTORY FILE Patient s Name: SS# First Middle Last Date of Birth: Patient
More informationMark H. Lowitt, M.D., LLC Nicoleta Negoita, MS, PA-C Sherry G. Cohen, MS, NP-C Juan (Julia) Liu, PhD, MMS, PA-C
Mark H. Lowitt, M.D., LLC Nicoleta Negoita, MS, PA-C Sherry G. Cohen, MS, NP-C Juan (Julia) Liu, PhD, MMS, PA-C GBMC Physicians Pavilion East (Iris Parking Garage) 6565 N. Charles Street Suite 315 Baltimore,
More informationLAWRENCE 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
More informationPATIENT / VISIT INFORMATION PATIENT INFORMATION
PATIENT / VISIT INFORMATION PATIENT INFORMATION Name of Patient: Date of Birth: Date of Visit: VISIT INFORMATION Please complete this form in its entirety, and present it to the registration desk when
More informationPATIENT INFORMATION PATIENT NAME (LAST, FIRST, MIDDLE) SEX DOB MAILING ADDRESS CITY STATE ZIP SSN
PATIENT INFORMATION PATIENT NAME (LAST, FIRST, MIDDLE) SEX DOB MAILING ADDRESS CITY STATE ZIP SSN STREET ADDRESS (IF DIFFERENT FROM ABOVE) CITY STATE ZIP HOME PHONE NUMBER EMPLOYER CELL PHONE NUMBER WORK
More informationMICHAEL D BROOKS, DMD, MS, PLLC MICHAEL J BOWMAN, DDS, MS, PLLC PATIENT INFORMATION RECORD DENTAL INSURANCE
PATIENT INFORMATION RECORD NAME DATE DATE OF BIRTH SEX SOCIAL SECURITY HOME ADDRESS HOME PH EMAIL CITY STATE ZIP EMPLOYER OTHER PH DENTAL INSURANCE PRIMARY SUBSCRIBER NAME SOCIAL SECURITY # DATE OF BIRTH
More informationGuardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.
More informationOrthopedic 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
More informationIN CASE OF EMERGENCY
THE INFORMATION REQUESTED ON THIS FORM IS USED TO FILE MEDICAL CLAIMS AND FOR OTHER IMPORTANT MEDICAL DOCUMENTATION. PLEASE PRINT LEGIBLY SO THAT WE MAY ACCURATELY REFLECT YOUR PERSONAL INFORMATION IN
More informationRIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
More informationSHREVEPORT-BOSSIER FAMILY DENTAL CARE
SHREVEPORT-BOSSIER FAMILY DENTAL CARE Patient's Name: Patient's Birthdate: (FIRST, MIDDLE, LAST) Patient's SSN #: Patient's Email Address: _ Patient's Phone #: Home:_ Cell: Work: Patient's Address: Patient's
More informationNotice 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
More informationSan Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your
More informationWelcome to our office. Providing you with exceptional care is the motivation and intention of our physicians and staff.
451 N. Texas Ave. 1401 Binz St, Suite 200 20320 Northwest Fwy. #700 Webster, TX 775988 Houston, TX 77004 Houston, Texas 77065 Stephen Tyring, MD, PhD Karan Sra, MD Lauren Campbell, MD Payel Patel, DO NEW
More information1960 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
More informationWelcome 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
More informationDate. Initial. Initial. Minor ADDRESS. Cash ADDRESS
PATIENT NAME IF CHILD: PARENT'S NAME HOW DO YOU WISH TO BE ADDRESSED Single Married RESIDENCE - STREET Separated Divorced Widowed CITY STATE ZIP TELEPHONE: RES. EMAIL ADDRESS PATIENT/PARENT EMPLOYED BY
More informationMedicare Supplement plan application
Medicare Supplement plan application SECTION 1 Personal information Last name First name Middle initial Social Security number - - Primary Street address City State ZIP code Mailing Street address (if
More informationPATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
More informationWelcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
More informationGastroenterology Associates, N.A. P.C. Patient Demographic & Insurance Information
Gastroenterology Associates, N.A. P.C. Patient Demographic & Insurance Information Basic Patient Information Patient s Social Security Number: Date: Name of Patient: First Middle Last Birth Date: Age:
More informationPersonal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
More informationMVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
More informationAlldent Dental Center Patient Registration
Patient Registration DATE Patient Name Age Address Home Phone Cell City State Zip Email Social Security # Date of Birth Sex: M F Single Married Divorced Widowed Separated Employed by Occupation Business
More informationPatient 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:
More informationPatient 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:
More informationOrthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: 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
More informationCONSENT FOR MEDICAL TREATMENT
CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern
More informationRoswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
More informationYes/No. Are You ALLERGIC to any medications? Please specify:
Current Medications: (please include over the counter medications and food supplements) Drug Name: Dose How often? Are You ALLERGIC to any medications? Please specify: Yes/No Past Medical History: Please
More informationPatient 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,
More informationHow To Contact A Doctor From A Doctor'S Office
Anthony S. Lombardi, MD, FACS Nilla Defazio, PA C Jessica Henderson, PA C PATIENT INFORMATION Date Patients Last Name First Name M.I. Suffix(i.e,Jr.,Sr.) Street Address City State Zip Code ( ) ( ) M S
More information(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
More informationALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province:
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 informationAMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224
AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224 For AHL Home Office use only tes EVIDENCE OF INSURABILITY AND ENROLLMENT FORM Check appropriate
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 informationThe 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.
More informationName 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
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 informationPhysical Therapy Services Medical History Form
Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently
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 informationPatient Information & Medical Screening Form
Patient Information & Medical Screening Form Name: Date of Birth: Social Security Number: Status: Single Married Divorced Widowed Other Ethnicity: Caucasian African American Hispanic Asian American Indian
More informationPATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)
More informationNearest Relative Information (Not in same household)
Patient Information Name Male Female Address City State Zip Birth Date Age Responsible Party Information Name: Self Parent/Guardian Birth Date SSN# Drivers License# Email Employer Employer Phone# Employer
More informationWelcome to Tri-State Rehab Services
Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely
More informationNew Patient Registration Form
New Patient Registration Form Welcome to Bayside Dental Care! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
More informationINTEGRATED PHYSICAL THERAPY a whole- istic approach to physical therapy
Patient s Name: D.O.B.: Age: Address: City: State: _ Zip Code: Home Phone #: Cell #: _ Business #:_ Social Security Number: E- mail Address: Referring Physician? _ How do you hear about us: Dr. Referral
More informationTHANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! Please complete and sign all of the enclosed forms. Bring these forms, your physician s referral if required and any other documents required
More informationLake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600
PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company
More informationORANGE COUNTY EYE INSTITUTE
ORANGE COUNTY EYE INSTITUTE *Note: It is the patient s responsibility to file insurance claims if we are not contracted with your insurance company. *Note: Be aware that most medical insurance plans do
More informationName: 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):
More informationWELCOME PATIENT CONDITION
NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer
More informationWelcome to Manhattan Dental Studio, where delivering quality dental care for optimal health is
Welcome to Manhattan Dental Studio, where delivering quality dental care for optimal health is our main objective. You can rest assured in knowing that Dr. Tomack and Dr. Behrens have your best interest
More informationWelcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our facility.
AVIDAPT 1391 Dublin Rd, Columbus, OH 43215 614-487-9715 avidapt.com Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our
More informationPatient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
More informationCONSENT FOR TREATMENT
PATIENT INFORMATION PERSON FINANCIALLY RESPONSIBLE LAST NAME FIRST M.I. NAME RELATIONSHIP TO PATIENT PREFERS TO BE CALLED BY MALE FEMALE BIRTH DATE SOCIAL SECURITY NO. BIRTH DATE SOCIAL SECURITY NO. ADDRESS
More information920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com Thank you for selecting Timberline to be a part of your rehabilitation. Below we have condensed
More informationPhysician address. Physician phone
PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center www.michigansportsmedicine.com Your family physician
More informationRETINA 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
More informationInsured 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
More informationName: Phone: Ins. Co: Group #: ID# Phone #: Name of Insured: Relationship to patient: SS#: / / DOB: / / Employer: Phone:
PATIENT INFORMATION Thank you for choosing us as your dental care provider. We look forward to caring for you! Patient Information: Patient Name (First Middle Initial Last): DOB: / / SS#: / / Driver s
More informationAdvanced Rheumatology of Houston Offices of Dr. Tamar F Brionez
Advanced Rheumatology of Houston Offices of Dr. Tamar F Brionez New patient history form Patient name DOB Allergies to Medicines: Current Medications Name Dose Times/day taken Social History Married/single/widowed/divorced
More informationMEDICAL & 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
More informationTrinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with
More informationNew Patient Registration Information
New Patient Registration Information ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center........ (717) 339-2620 Apple Hill................ (717) 741-8240 Aspers Health Center........ (717)
More informationResponsible Party Information (IF DIFFERENT FROM ABOVE)
Last Name: First Name: Middle Initial: Address: City: State: Zip: Home Phone: Cell Phone: Other Phone: Email Address: Are there any restrictions in contacting you? (No) (Yes) Explain Date of Birth: Age:
More informationLITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION
A-02 form.patient.demographic.information Rev. (01/14) DATE: SIGNATURE: PHYSICIAN (PLEASE PRINT) LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION PATIENT'S FULL NAME ADDRESS APT. # CITY STATE
More informationWELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
More informationPATIENT REGISTRATION AND HISTORY FORM ~ FAMILY EYE HEALTH ASSOCIATES
PATIENT REGISTRATION AND HISTORY FORM ~ FAMILY EYE HEALTH ASSOCIATES PATIENT INFORMATION: Name (Last, First, MI) Date: Address: City State Zip Home Phone 2nd Phone Work Cell E-Mail Gender: M F Birthdate
More informationNew River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
More information