CONSENT FOR MEDICAL TREATMENT

Size: px
Start display at page:

Download "CONSENT FOR MEDICAL TREATMENT"

Transcription

1 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 affecting me at any time I am present at Gold Canyon Urgent Care & Family Medicine for care. These services may include, but are not limited to, laboratory procedures, drug screen, x-ray examinations, and medical or surgical treatment or procedures. I have read and understand this treatment agreement. I am the patient, the parent of a minor child, or the legally authorized representative of the patient and am authorized to act on behalf of the patient and to sign this agreement. Gold Canyon Urgent Care & Family Medicine has the permission to request and download the medication history from my pharmacy. FINANCIAL POLICY/ADVANCE BENEFICIARY NOTICE OF NON COVERAGE All patients must provide accurate and complete personal and insurance information prior to being seen by the doctor. Payment is required at the time of service and may be in the form of cash, debit, or credit card. Gold Canyon Urgent Care & Family Medicine may disclose all or part of a patient s medical or financial records (including information related to alcohol and drug abuse, mental health diagnosis and treatment, HIV related or other communicable disease related information) to third parties to obtain payment for services provided. We will gladly file a claim with your insurance company. It is your responsibility to comply with any pre-determination or notification requirements of your insurance plan. Many of the services provided may be covered and paid for by your insurance company. Unfortunately, insurance companies do not pay for all services that the provider may deem appropriate. In all cases we require the guarantor, the person who is financially responsible, to be personally liable for all balances. The Guarantor agrees to pay any and all applicable fees should the account be referred to an outside collection agency, including, and not limited to 33% of the account balance at the time it is sent to collections. We believe the fees we charge to be reasonable and customary fees for our region and specialty. If your insurance company uses a different fee schedule, you may be responsible for any balance remaining. Gold Canyon Urgent Care & Family Medicine may charge reasonable fees for services related to your account including, but not limited to, returned check fees, interest on unpaid accounts, and medical record copies. Your personal information will be verified and updated at each visit, to ensure information on file is accurate. We may collect a deposit on the charges you incur today toward your balance (e.g. copay, deductible, self pay) and bill you for any remaining balance. All bills are due upon receipt. Federal laws require that we submit every claim to an insurance company accurately and report the exact services performed and the exact reason for performing them. We are not allowed to change information just so the insurance company can pay a claim. I certify that the information provided is true and accurate. I assign any payable benefits to be paid directly to Gold Canyon Urgent Care & Family Medicine and authorize them to submit a claim on my behalf. I understand that I am financially responsible for any non-covered service. I authorize Gold Canyon Urgent Care & Family Medicine to release any information required to process claims for my care and treatment. I have read and understand the financial policy and agree to abide by it. ACKNOWLEDGEMENT OF PRIVACY ACT POLICY RIGHTS I have been made aware of Gold Canyon Urgent Care & Family Medicine privacy rights policy, consent for treatment and the financial policy. Signature Relationship to Patient Date Relationship to Patient Reason for Visit Witness 1

2 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY Use and Disclosure Treatment Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record for all health professionals who may provide treatment or who may be consulted by staff members. Reminders/Notifications Our staff will use your health information to send you follow-up care, referral or appointment reminders. We may also send you information describing changes occurring at Gold Canyon Urgent Care / Gold Canyon Family Medicine such as address changes, new locations or changes in business hours. Treatment Information Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. Payment Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided and the medical condition being treated. Healthcare Operations Your health information may be used as necessary to support the day-to-day activities and management of Gold Canyon Urgent Care / Gold Canyon Family Medicine. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Law Enforcement Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting. Public Health Reporting Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state s public health department. Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization. 2

3 INDIVIDUAL RIGHTS You have certain rights under the federal privacy standards. These include: The right to request restrictions on the use and disclosure of your protected health information, The right to receive confidential communications concerning your medical condition and treatment, The right to receive confidential communications concerning your medical condition and treatment, The right to inspect and copy your protected health information, The right to an accounting of how and to whom your protected health information has been disclosed, The right to receive a printed copy of this notice. Gold Canyon Urgent Care/Gold Canyon Family Medicine Care Duties We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain. Complaints If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Gold Canyon Urgent Care 6820 S. Kings Ranch Rd. Suite 130 Gold Canyon, AZ If you believe that your privacy rights have been violated, you should bring the matter to our attention by sending a letter describing the cause or your concern to the address listed above. You will not be penalized or otherwise retaliated against for filing complaint. This is effective on or after October 8,

4 PATIENT REGISTRATION FORM Last Name: First Name: MI: Birth date: SSN: Gender: Male Female Primary Address: City: State/Zip: Home Phone: Cell Phone: Race Ethnicity: Preferred Language: Secondary Address: City: State/Zip: Emergency Contact: Phone: Relationship: Relative Friend Reason for today s visit: Primary Pharmacy: How did you hear about us? Location: Family/Friends AJ News Independent News Copper News Television Internet Drive by/signage Other MINORS ONLY Mother: Last Name: First Name: MI: Birth date: SSN: Phone: Primary Address: City: State/Zip: Father: Last Name: First Name: MI: Birth date: SSN: Phone: Primary Address: City: State/Zip: INSURANCE INFORMATION Primary Insurance: Secondary Insurance: Policy Number: Group Number: Policy Number: Group Number: (If policy holder is NOT patient) Policy Holder: Relationship to Patient: Birth date: SSN: Personal Phone: Work Phone: Primary Address: City: State/Zip: 4

5 HEALTH HISTORY SHEET Date: Patient s Name: Date of Birth: Age: This history form provides us with information to help us meet all your health care needs, please complete this form answering each question. This is a confidential part of your medical record and will be kept in this office. HABITS Do you smoke? Y N How many Packs a day? Have you ever quit smoking? Y N Do you drink alcohol? Y N How often? Drink caffeine? Y N How often? Do you use recreational drugs? Y N What type? How often? PATIENT HISTORY Y N Coronary Artery Disease (CAD) Y N Essential Hypertension Y N Hyperlipidemia Y N Diabetes Type I or II Y N HIV Infection Y N Asthma Please list ALL allergies you may have to medications, food and environment Please list ALL operations, conditions and hospitalization you have had; also include the year they occurred Please list ALL medications you are currently taking (include nonprescription drugs) Last Menstrual Period (LMP) Date: 5

6 **PLEASE SPECIFY REASON FOR TODAY S VISIT** Please list (in order of importance) health concern, symptoms, or problems you are experiencing. FAMILY HISTORY Please select any family member who has or has had any of the following: Cancer: Father Mother Sibling Other Heart Disease: Father Mother Sibling Other High Blood Pressure / Hypertension: Father Mother Sibling Other Early Death: Father Mother Sibling Other Depression: Father Mother Sibling Other Stroke: Father Mother Sibling Other Obesity: Father Mother Sibling Other Migraine Headaches: Father Mother Sibling Other High Cholesterol: Father Mother Sibling Other Drug/Alcohol problems: Father Mother Sibling Other Other: Father Mother Sibling Other Please list family member s health status: Good, Fair, Poor, or Deceased (At Age) Mother Father Siblings Children IMMUNIZATIONS Are all immunization up to date? Y N Tetanus within last 10 years? Y N To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is also my responsibility to inform the doctor s office of any changes in my medical status. I also authorize the staff to perform the necessary health care services I may need. Signature Date 6

7 Reason for Visit: Staff Member: VERIFICATION FORM Patient Name: DOB: SS#: Phone #: Address: INSURANCE INFORMATION Primary Insurance: ID#: Group#: Phone #: Address: Subscriber s Name: DOB: SS#: Secondary Insurance: ID#: Group#: Phone #: Address: Subscriber s Name: DOB: SS#: Tertiary Insurance: ID#: Group#: Phone #: Address: Subscriber s Name: DOB: SS#: 7

8 ADVANCE DIRECTIVE According to Arizona State Law we must inquire about your Advance Directive What is an Advance Directive? An Advance Directive is a written document (like a Living Will, Durable Health Care Power of Attorney etc.) that explains what a person wants or doesn t want in the event they cannot make their wishes known regarding medical treatment. Among these treatments are life-sustaining efforts, CPR, organ/tissue donations, terminal conditions, autopsy etc. Yes No (Please circle) Do you have an Advance Directive? Yes No (Please circle) Have you provided Gold Canyon Urgent Care & Family Medicine a copy of your Advance Directive? Patient Signature: Date: The Arizona State Legislature created the Arizona Advance Health Care Directive Registry in May The Registry is a database for the storage of advance directives. The Arizona Secretary of State oversees its security and operations. Free of charge, you can setup and store your Advance Directives this helps you ensure the health care decisions you have made in advance are followed. If you have questions or want to file your directives go to under the Advance Directives section or call (602)

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Stonebridge Adult Medicine, P.A. Registration Form (Please Print) Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female

More information

Keweenaw Holistic Family Medicine Patient Registration Form

Keweenaw Holistic Family Medicine Patient Registration Form Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend

More information

BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES

BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established

More information

Advanced Rheumatology of Houston Offices of Dr. Tamar F Brionez

Advanced 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 information

New Patient Information Form

New Patient Information Form PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

Nephrology Associates New Patient Registration Forms

Nephrology Associates New Patient Registration Forms Registration Information Authorization form: Last First Middle Address: City: State: Zip: DOB: / / - - Home # ( ) - - Cell # ( ) - - Email Address: Alternate Contact Information Phone Number Relationship

More information

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

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

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C.

HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C. Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C., to provide Care and Treatment to considered necessary

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who 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 information

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia

More information

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information

IMS 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

Hand & Orthopedic Physical Therapy Associates, P.C.

Hand & Orthopedic Physical Therapy Associates, P.C. Patient Name: Hand & Orthopedic Physical Therapy Associates, P.C. Date of Birth: ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) NOTE: If Medicare doesn t pay for items listed below, you may have to pay.

More information

WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future.

WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future. Phone: 717-234-2561 Franklyn J. Myers, III, M.D., F.C.C.P. Alexis B. Aaronson, M.S.N, C.R.N.P. Michele M. Knepper, C.R.N.P. WELCOME TO PCCMA Welcome to our practice. We are specialists in the treatment

More information

New Perspective Counseling Services Child/Teen Intake Form

New Perspective Counseling Services Child/Teen Intake Form Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.

More information

WELCOME TO TRI-COUNTY EYE CLINIC

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,

More information

Virginia South Psychiatric & Family Services

Virginia South Psychiatric & Family Services All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow

More information

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 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.

More information

Choptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL

Choptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline County Public School system, your child has access to the School-Based

More information

Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com

Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com 1 Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com DEMOGRAPHICS & INSURANCE Patient Information Name: (First) (MI) (Last) SS#: DOB: Sex: Male Female Address:

More information

Cell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay:

Cell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay: DUS Family Medical Practice, LLC 7525 Greenway Center Drive, Suite # 105 Greenbelt, MD 20770 Phone: (301)313-0425 Fax: (301)313-0435 Patient s Last Name: First Name: MI: Address: City: State: Zip Code:

More information

Tell Us About Your Child. Dental History. Medical History

Tell Us About Your Child. Dental History. Medical History Tell Us About Your Child Today s Date Social Security# Child s Name: Child s Birthdate: Last First MI Child s Age: Nickname Male Female School Grade Child s Home Address: Who may we thank for referring

More information

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. 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 information

UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM

UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home

More information

General Medical Questionnaire

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)

More information

Signature: Date: Witness:

Signature: Date: Witness: : Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Home Telephone:( ) Referred By: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone

More information

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

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit. Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)

More information

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. 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)

More information

This is your copy of our privacy notice so please take it home with you and read it carefully.

This is your copy of our privacy notice so please take it home with you and read it carefully. Main 2219 E. Seventh Street South Charlotte 7000 Shannon Willow Rd Charlotte, NC 28226 Charlotte 2607 E. Seventh Street Suite 200 Monroe 1315 E. Sunset Drive Suite 201 Monroe, NC 28112 North Charlotte

More information

Personal Contact and Insurance Information

Personal Contact and Insurance Information Kenneth A. Holt, M.D. 3320 Executive Drive Tele: 919-877-1100 Building E, Suite 222 Fax: 919-877-8118 Raleigh, NC 27609 Personal Contact and Insurance Information Please fill out this form as completely

More information

155 McDonald Drive SW Shirley E. Charette, MS, PA-C

155 McDonald Drive SW Shirley E. Charette, MS, PA-C LAKELAND FAMILY MEDICINE Dennis J. Charette, M.D. 155 McDonald Drive SW Shirley E. Charette, MS, PA-C Carri A. Meiler, MS, PA-C Phone: 330-308-8999 Fax: 330-308-8016 www.lakelandfamilymedicine.com PATIENT

More information

BILLING INFORMATION AND ASSIGNMENT OF BENEFITS

BILLING INFORMATION AND ASSIGNMENT OF BENEFITS BILLING INFORMATION AND ASSIGNMENT OF BENEFITS Facility: Northpoint Radiation Center Pro Physicians Clinic PA Physician: Timothy D. Nichols, M.D. PA, Board Certified Radiation Oncology Wilhelm J. Lubbe,

More information

FAMILY CONTACT INFORMATION

FAMILY CONTACT INFORMATION FAMILY CONTACT INFORMATION -------------------- PLEASE COMPLETE THIS FORM IN BLACK INK ONLY -------------------- Date Account # Children Names DOB Gender School Goes By Cell Phone # Email Address Please

More information

Physical Therapy Services Medical History Form

Physical 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 information

EXCEL PHYSICAL THERAPY, INC.

EXCEL PHYSICAL THERAPY, INC. EXCEL PHYSICAL THERAPY, INC. Medical History Form Name: Date of Birth: Date: Are you employed? YES NO Right Handed Left Handed If NO, last day worked? Do you smoke? YES NO #of packs/day Occupation: Height:

More information

IN CASE OF EMERGENCY

IN 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 information

Patient Registration Please Print Patient Name Last First Middle

Patient Registration Please Print Patient Name Last First Middle Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact

More information

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM DATE: CHART#: GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: ADDRESS: HOME PHONE: ADDRESS: CITY/STATE: ZIP CODE: **************************************************************************************

More information

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments

More information

Patient History Information

Patient History Information Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred

More information

New Patient Information

New 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 information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Patient Information Street Address City State Zip Home Phone SSN of Birth Gender Male Female Work Phone Cell Phone Marital

More information

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

San 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 information

1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com

1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first

More information

Advanced Women's HealthCare, SC Registration Form

Advanced Women's HealthCare, SC Registration Form Patient Full Name Address Advanced Women's HealthCare, SC Registration Form Street Account # Provider Last First Middle Maiden(0ther) Apt/Suite# City State Zip Code Phone # (Please circle preferred contact

More information

PATIENT /GUARDIAN SIGNATURE

PATIENT /GUARDIAN SIGNATURE PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):

More information

LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION

LITTLE 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 information

Patient Registration Form

Patient Registration Form Patient Registration Form Name (Last, First, Middle) SSN# Age Marital Status Maiden Name Address Patient Home Phone Patient Business Phone Patient Cell Phone Patient E-mail Patient Occupation Business

More information

Midha Medical Clinic REGISTRATION FORM

Midha Medical Clinic REGISTRATION FORM Midha Medical Clinic REGISTRATION FORM Today s / / (PLEASE PRINT NEATLY) PATIENT INFORMATION Last Name: First Name: Middle Initial: IS THIS YOUR LEGAL NAME? YES NO IF NOT, WHAT IS YOUR LEGAL NAME DATE

More information

MVA Accident Questionnaire

MVA 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 information

Patient Information Form Trinity Wellness Center. Insurance Information

Patient Information Form Trinity Wellness Center. Insurance Information Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # -- -- Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student

More information

HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME

HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME We are pleased you have chosen us for your physical therapy needs. Our office is committed to providing

More information

North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email

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:

More information

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) 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:

More information

In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT

In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT 1) PATIENT REGISTRATION ACCT #: DR.: APPT. DATE: FIRST NAME MIDDLE LAST

More information

Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax

Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have

More information

REHAB XCEL, LLC. NEW PATIENT INFORMATION

REHAB XCEL, LLC. NEW PATIENT INFORMATION REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S

More information

PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:

PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email

More information

DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female

DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

REGISTRATION FORM. How would you like to receive health information? Electronic Paper In Person. Daytime Phone Preferred.

REGISTRATION FORM. How would you like to receive health information? Electronic Paper In Person. Daytime Phone Preferred. Signature Preferred Pharmacy Referral Info Emergency Contact Guarantor Information Patient Information Name (Last, First, MI) REGISTRATION FORM Today's Date Street Address City State Zip Gender M F SSN

More information

Welcome To Our Physical Therapy Department

Welcome To Our Physical Therapy Department Welcome To Our Physical Therapy Department Our entire staff is dedicated to providing our patients with the best possible care and service while keeping the costs to you from increasing at an unreasonable

More information

Choptank Community Health System School Based Dental Program Healthy Children Are Better Learners DENTAL

Choptank Community Health System School Based Dental Program Healthy Children Are Better Learners DENTAL School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline, Dorchester and Talbot County Public School system, your child has access to the

More information

Policy Holder Name Relationship to Patient SSN DOB

Policy Holder Name Relationship to Patient SSN DOB Orthopedic Today s Date Patient s SSN# Legal First Name Last Name M.I. DOB Gender Parent/Guardian Name (for pediatrics) DOB Address City State Zip Home Phone Cell Phone Work Phone Email Have any members

More information

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax)

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) PATIENT INFORMATION: Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) Last Name: First: MI: Address: City:

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

More information

EMERALD COAST CANCER CENTER 1024 MAR WALT DRIVE 7720 HWY 98 WEST STE 240 FT. WALTON BEACH, FL 32547 DESTIN, FL 32550

EMERALD COAST CANCER CENTER 1024 MAR WALT DRIVE 7720 HWY 98 WEST STE 240 FT. WALTON BEACH, FL 32547 DESTIN, FL 32550 EMERALD COAST CANCER CENTER 1024 MAR WALT DRIVE 7720 HWY 98 WEST STE 240 FT. WALTON BEACH, FL 32547 DESTIN, FL 32550 NEW PATIENT INFORMATION FORM - PLEASE PRINT LEGIBLY - THANK YOU. PATIENT S NAME DATE

More information

NOTICE OF PRIVACY PRACTICES. The University of North Carolina at Chapel Hill. UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates

NOTICE OF PRIVACY PRACTICES. The University of North Carolina at Chapel Hill. UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates NOTICE OF PRIVACY PRACTICES The University of North Carolina at Chapel Hill UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

More information

INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES

INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YU CAN GET ACCESS TO THIS INFORMATION- PLEASE REVIEW IT CAREFULLY

More information

NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280

NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 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 information

Patients Last Name First Name M.I. Suffix(i.e,Jr.,Sr.) Street Address City State Zip Code

Patients Last Name First Name M.I. Suffix(i.e,Jr.,Sr.) Street Address City State Zip Code 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

Patient or Guardian Signature

Patient or Guardian Signature Co Payment Policy According to the regulations of individual insurance carriers, patients are responsible for paying co payments at the time of each office visit. PAYMENT POLICY FOR SERVICES RENDERED If

More information

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515 : / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell

More information

Centennial Family Medicine & Wellness PATIENT DEMOGRAPHIC INFORMATION FORM Patient s Full Name (List all name if more than one child)

Centennial Family Medicine & Wellness PATIENT DEMOGRAPHIC INFORMATION FORM Patient s Full Name (List all name if more than one child) Centennial Family Medicine & Wellness PATIENT DEMOGRAPHIC INFORMATION FORM Patient s Full Name (List all name if more than one child) Physician: Date of Birth Gender Social Security PARENT/GUARDIAN S NAME:

More information

! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002

! 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 information

626 Dallas Hwy PO Box 1008 Villa Rica, GA 30180 PATIENT INFORMAION PARENT INFORMAION INSURANCE INFORMATION (PARENT WHO PAYS FOR INSURANCE)

626 Dallas Hwy PO Box 1008 Villa Rica, GA 30180 PATIENT INFORMAION PARENT INFORMAION INSURANCE INFORMATION (PARENT WHO PAYS FOR INSURANCE) WESTCARE VILLA RICA PEDIATRICS 626 Dallas Hwy PO Box 1008 Villa Rica, GA 30180 Phone: 770 459 9378 Fax: 770 459 8613 Email: westcarepeds@aol.com DATE PATIENT INFORMAION Child s Name Date of Birth Sex Address

More information

HSE Medical Associates Family Practice

HSE Medical Associates Family Practice HSE Medical Associates Family Practice PLEASE CHECK WHICH PROVIDER YOU ARE HERE TO SEE M.D. P.A. David W. Hoefer, M.D. Paul E. Shepard, M.D. Alfredo T. Ermac, M.D. Sergio G. Perossa, Darcy Bevil, P.A.

More information

PEDIATRIC MEDICAL HISTORY FORM

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

More information

Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated

Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Patient Information Last Name First Name MI Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Race (circle): Black White Asian Other Ethnicity

More information

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Single 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 information

HIPAA Security Manual Administrative Security/Omnibus Rule

HIPAA Security Manual Administrative Security/Omnibus Rule Notice of Privacy Policies Form ***This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE READ IT CAREFULLY!*** The tells

More information

BARNIDLL SPORTS MEDICINE 7000 W. 9th Ave. Amarillo, TX 79106 (806) 350-3500 www.barnhillsportsmed.com

BARNIDLL SPORTS MEDICINE 7000 W. 9th Ave. Amarillo, TX 79106 (806) 350-3500 www.barnhillsportsmed.com BARNIDLL SPORTS MEDICINE 7000 W. 9th Ave. Amarillo, TX 79106 (806) 350-3500 www.barnhillsportsmed.com ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE I acknowledgement that I have received a copy of Barnhill

More information

Your appointment is scheduled for at with Dr. Your arrival time is.

Your appointment is scheduled for at with Dr. Your arrival time is. Dear : We appreciate your selection of our office for your complete eye care. Your appointment is scheduled for at with Dr. Your arrival time is. First visits usually take approximately one and a half

More information

HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)

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

More information

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH# Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:

More information

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient

More information

CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET. Last First Middle Name: Name: Initial: Male: Address: City: State: Zip:

CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET. Last First Middle Name: Name: Initial: Male: Address: City: State: Zip: CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET Last First Middle Initial: Male: Is this your legal name? Female: Yes / no If not, what is your legal name: Address: City: State: Zip:

More information

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called? Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address

More information

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST

More information

ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012)

ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012) ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012) PATIENT REGISTRATION FORM & FINANCIAL PAYMENT POLICY Patient Info: Please print

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM 201 N. Park Ave Suite 201 Apopka, FL 32703 Office (407)228-3180 Fax: (407)-228-3725 PATIENT REGISTRATION FORM Last Name: First Name: Middle Initial Male Female Date of Birth: Marital Status: Single Married

More information

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment.

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment. Conroe Physician Associates Patient Consent Form Please Read and Sign I, undersigned, hereby consent to the following: Administration and performance of all treatments Administration of any needed anesthetics

More information

P.S. Please remember to bring your completed forms to your office visit!

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

More information

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER:

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER: NOTICE OF PRIVACY PRACTICES COMPLETE EYE CARE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

AGREEMENT AND INFORMATION

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

More information

!!!! Infectious Disease Center of New Jersey, LLC! Any Allergies: Family History:! Mom:! Dad: Your Medical History:

!!!! Infectious Disease Center of New Jersey, LLC! Any Allergies: Family History:! Mom:! Dad: Your Medical History: Infectious Disease Center of New Jersey, LLC 22 Old Short Hills Road P: 973-535-8355 Suite 106 F: 973.535.8353 Livingston NJ 07039 IDCOFNJ@gmail.com Patient Name Any Allergies: Family History: Mom: Dad:

More information

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code:

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code: Atlanta Diabetes Associates Patient Registration Form : Chart #: Which Doctor are you seeing today: _ Patient Name: First Middle Last Address: City: State: Zip Code: _ Home Phone: Work Phone: of Birth:

More information

650 Clark Way Palo Alto, CA 94304 650.326.5530

650 Clark Way Palo Alto, CA 94304 650.326.5530 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. (Adopted 4-14-03; revised December 2006) If

More information