When you arrive for your first appointment, please bring the following with you:

Size: px
Start display at page:

Download "When you arrive for your first appointment, please bring the following with you:"

Transcription

1 115 N. Sumter Street, Suite 400, Sumter, SC Phone (803) (SICK) / Fax (803) WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your primary care! It is our responsibility to deliver the best care possible to you and your family. We are a full spectrum family practice specializing in the care of patients of all ages. BUSINESS HOURS Monday: 8 a.m. 5 p.m. Tuesday: 8 a.m. 5 p.m. Wednesday: 8:00 AM 1:00PM Thursday: 8 a.m. 5 p.m. Friday: 8 a.m. 5 p.m. Patients are seen by scheduled appointments only. After-hours care is coordinated through our answering service. Patients will be directed to the appropriate On-Call physician for Carolina Family Medicine of Sumter by calling our office after hours, including weekends and holidays. We are affiliated with Tuomey Regional Medical Center as a practice of the Tuomey Medical Professionals Inc. If hospitalization is needed, you will be seen by your physician from Carolina Family Medicine of Sumter while in the hospital. PREPARING FOR YOUR VISIT In order to make your first visit more effective, please notify your health insurance company in advance of your appointment and your new primary care provider, if required by your health insurance plan. Please be on time for your appointments in order to keep your doctor on schedule. If you are late, your appointment MAY be rescheduled for the next available New Patient opening. Please arrive 15 minutes early if you have completed the new registration forms prior to your appointment, to allow plenty of time for our staff to get you registered for your appointment. If you are unable to complete this packet, please arrive 30 minutes early to allow plenty of time to complete your paperwork before your scheduled appointment. You may bring your paperwork by prior to your scheduled appointment or you may fax it to When you arrive for your first appointment, please bring the following with you: 1. All of your health insurance cards (we ask for them at every visit) 2. Photo Identification (current driver s license, state issued ID, student ID, military ID, or Passport) 3. All medications you are currently taking, including vitamins and over-the-counter medications. 4. Completed registration forms 5. Payment is due at the time of service. This includes all copays, co-insurance, deductibles or self-pay visits.

2 Please call our office if you have any questions or need to reschedule your first appointment. We do require 24- hour s notice if you are unable to keep your scheduled appointment. LABORATORY TESTING We draw labs in the office and depending on your insurance carriers preferred lab or your personal preference, your labs will be sent to one of the following laboratories for resulting: Tuomey, LabCorp, or Quest Diagnostics. Please fill out the enclosed Lab Testing form to indicate your preferred lab. All lab results must be reviewed by the physician prior to being released to the patient. Please allow 1-2 weeks for the clinical staff to call with the results. Urgent results are handled as first priority when notifying patients. The clinical staff will attempt to contact you with lab results twice via phone. If the clinical staff cannot reach you, then your results will be mailed to the address on file. MINORS Please make sure that you fill out the Health Care Surrogate Designee(s) form if you are the parent or legal guardian of a minor child being treated at Carolina Family Medicine of Sumter. If anyone other than the parent or legal guardian brings a minor to an appointment and they are not listed on the form we will NOT be able to see or treat the minor. MEDICATIONS Please bring all medications (prescription and over-the-counter) to all appointments. We must compare your medications bottles to our records to make sure you are taking the prescribed medication appropriately and to check for refills. If you request a prescription to be written or called into your pharmacy, please allow 24 hours for us to process your request. We must get authorization from the physician prior to writing or calling in your prescription. INSURANCE/BILLING Please be sure to bring all of your insurance cards to every visit. Payment is expected at the time of service for every visit. If you are unable to make your payment, please contact the Billing Office at least 24 hours prior to your scheduled appointment. If there is a change in your insurance coverage, please notify us immediately. There are filing deadlines and contractual agreements that we must abide by. If the correct insurance is not filed, it could result in the patient being responsible for the balance for that particular date of service. Your insurance is filed as a courtesy. However, if we are not contracted with your insurance company, we file the claim as an out of network provider. You will be responsible to pay 100% of your visit upon check-out. If your insurance company reimburses the charges for that date of service, we will refund your payment. These guidelines are in place so that every patient receives the best quality of care possible. We are honored that you have chosen us to be your primary care practice and look forward to a long and healthy relationship.

3 REGISTRATION FORM PATIENT INFORMATION PLEASE COMPLETE ALL INFORMATION Last Name: First Name: Middle: Previous Last Name: Is this your legal name? If not, what is your legal Social Security # Date of Birth: Sex: Yes No name? - - / / M F Physical Address: City: State: Zip Code: Mailing Address/PO Box: City: State: Zip Code: Marital Status: Single Married Divorced Widowed Separated Language: English Spanish Other: Race: African American Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander White Home Phone: ( ) Work Phone: ( ) Mobile Phone: ( ) Address: Contact Preference: Home Work Mobile Other: Emergency Contact: Emergency Contact Phone Number: Relationship: ( ) Employment: Employer: Student Status: Employed Unemployed Full Time Self Employed Retired Not a Student GUARANTOR INFORMATION PERSON RESONSIBLE FOR BILL Name of Guarantor: Mailing Address of Guarantor: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Do not wish to report Phone Number of Guarantor: Guarantor s Date of Birth: Guarantor s Social Security #: ( ) INSURANCE INFORMATION PLEASE COMPLETE ALL INFORMATION Primary Insurance Company: Policy Number/Member ID: Group Number: Part Time Address: City: State Zip Code: Phone Number: ( ) Policy Holder s Name: Policy Holder s SSN: Policy Holder s Date of Birth: Relationship to Patient: - - / / Secondary Insurance Company: Policy Number/Member ID: Group Number: Address: City: State Zip Code: Phone Number: ( ) Policy Holder s Name: Policy Holder s SSN: Policy Holder s Date of Birth: Relationship to Patient: - - / / The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the practice. I understand that I am financially responsible for any balance. I also authorize Carolina Family Medicine of Sumter or my insurance company to release any information required to process my claims. Signature of Patient or Legal Guardian Date

4 HEALTH CARE SURROGATE DESIGNEE(S) I (We) and, parent(s) or legal guardian of, authorize the adult(s) named in the list below to bring my minor child to Carolina Family Medicine of Sumter for, and consent to, treatment, or receive medical advice over the phone if they are taking care of my child in my absence. This does not let allow them to have access to protected health information that is not pertinent to the visit. Please check boxes to give them additional specific authorizations.* NAME BIRTHDATE RELATIONSHIP TO MINOR AUTHORIZATIONS *Any other type of documents to be picked up by someone other than the legal guardians listed above must have written consent from the legal guardian(s). I (We) understand that telephone triage and advice services will not be extended to the above persons unless it is regarding direct patient care while the child is in their care. When the above listed individuals bring a minor child for their medical care at Carolina Family Medicine of Sumter, we will verify their identity by asking for a picture ID. If the individual bringing the minor child to the office visit does not have a picture ID and is not listed on this form, we will not be able to see the minor and the appointment will be rescheduled. Parent/Legal Guardian Name (print) Relationship to Patient Parent/Legal Guardian Signature Date This authorization shall remain in effect until revoked in writing with my signature.

5 Release of Information Declaration I, give permission for the following individuals to have access and availability to any and all of my protected health information at Carolina Family Medicine of Sumter. Please check which information (Medical, Financial or Both) you would like the persons to receive. Individuals not listed on this form and/or those who do not have a picture ID will not have any access to your protected health information. Name Date of Birth Relationship to Patient Authorizations Medical Financial Medical Medical Medical Financial Financial Financial Do you want results of lab tests/x-rays left on your answering machine or voic ? Home: Yes No Work: Yes No (We will still leave generic information on your answering machine or voic for an appointment or to call our office.) Do you want information given to your employer or school if they inquire about appointment absentee information? School: Yes No Employer: Yes No I authorize the staff to inform me by mail or phone (including home answering machines/voic ) of various reports if necessary. Yes No Should any lab tests or pathology be done during the visit, I would prefer that my labs/pathology be sent to one of the following labs: LabCorp Tuomey Quest I understand that I am responsible for making sure that the above chosen lab is my insurance company s lab of choice and if not I will be responsible for any charges occurred. Carolina Family Medicine only bills my insurance company for labs that are CLIA waived (i.e. finger sticks, rapid flu and strep tests, urine analysis, etc.). All other tests and pathology are billed to the patient s insurance by the lab selected. Yes No Rights of the Patient I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending a written notification to Carolina Family Medicine of Sumter. I understand that a revocation is not effective in cases where the information has already been disclosed, but will be effective going forward. I understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal and state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient in writing. I understand by signing this form that I am consenting to medical treatment by Carolina Family Medicine of Sumter. I understand by signing this form that I am consenting to release of medication history to Carolina Family Medicine of Sumter. Patient Name (Print) Date Patient or Authorized Representative s Signature Date

6 TUOMEY MEDICAL PROFESSIONALS, INC. CONSENT AND CONDITIONS OF TREATMENT In consideration of the care and treatment to be provided to the patient whose name appears at the bottom of this page at Tuomey Medical Professionals, Inc. ( TMP ) d/b/a Sumter Ob/Gyn, Industrial Medicine and Wellness, Sumter Surgical, Sumter Plastic and Reconstructive Surgery, Sumter Orthopedic Associates and Carolina Family Medicine of Sumter. I/we, the undersigned, consent to and agree to the following conditions. CONSENT FOR TREATMENT I/we voluntarily consent to healthcare treatment and diagnostic procedures provided by TMP and its associated physicians, clinicians, and other personnel. I/we further consent to testing for infectious diseases, including, but not limited to, syphilis, AIDS/HIV, hepatitis and testing for drugs if such testing is deemed advisable by my physician. I/we am/are aware that the practice of medicine and surgery is not an exact science and I/we acknowledge that no guarantees have been made as to the result of treatments or examinations. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I/we consent to the use and disclosure of my/the patient s protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment and health care operations consistent with the TMP s Notice of Privacy Practices. ASSIGNMENT OF BENEFITS AND PAYMENT I/we guarantee payment of all charges made for or on account of me/the patient. Unless my/the patient s account is paid in full upon discharge, I/we hereby assign the following to the physician and TMP: (1) my/our rights to any and all insurance benefits I/we have or to which I/we may become entitled; (2) the proceeds for all claims resulting from or relating to the liability of or payments made by a third party or by any person, employer, or insurance company on the third party s behalf to or for the patient; or (3) other funding. I/we understand that I/we am/are responsible for any charges not covered by insurance or other forms of benefits. I/we understand TMP can obtain my/our credit report for review in collection of this debt. For Medicare beneficiaries: I/we have provided all necessary information for proper assignment of Medicare benefits. PATIENT FINANCIAL POLICY It is the goal of TMP to provide the best of care on your behalf. Therefore, it is important for you to fully understand our insurance and collection policies. Please read the following information carefully and feel free to ask any questions. We ask that you initial this statement when you have read and understand each point covered. Upon registration, TMP may require a picture I.D. (if the patient is a minor a picture I.D. may be required of parent/legal guardian). In addition, each patient may be required to complete a Patient Information Form, Medical History and Consent and Conditions of Treatment. If we participate with HIPAA #1008A Consent and Conditions of Treatment

7 your insurance(s), a copy of your insurance card(s) will be required for verification of insurance coverage and benefits. If you have been referred to this office by your primary care physician and belong to an insurance plan that requires precertification or referral for this office visit, we request that you have this information available before you visit a physician. Failure to supply this information may postpone your visit to the physician or make you responsible for the full balance of your account. If you have health insurance, it should be understood that this is an agreement between you and your insurance carrier to pay for medical care. Your doctor s bill is an agreement between you and this office. You are ultimately responsible for the payment of your bill regardless of the status of your insurance claim. We will file all claims for those patients who are covered by insurance companies that our office has contracted to provide services within their fee schedule. The contracts are subject to change with or without notice. All copays are due at the time of service. If your insurance has a deductible, you will be required to pay any/all insurance allowed charges at the time of service. If you have your Explanation of Benefits from your insurance company (must be current year) that demonstrates that the deductible has been met, you will only be required to pay the percentage allowed by your particular insurance. You will receive regular statements (every 30 days) from our office informing you of the status of your balance. Please feel free to call our office, if you should have any questions. If we have not received any payment after 90 days from the date of service, we reserve the right to refer your account balance to an outside collection agency where you will be responsible for all collection and legal fees. There will be a $30.00 fee for all checks presented for payment with non-sufficient funds (bad checks). You will also be billed separately by the hospital or other sources, if it applies, for certain lab fees, radiology fees and/or outpatient or inpatient procedures, and orthopedic supplies (slings, braces, splints, etc.). NOTICE OF PRIVACY PRACTICES I/we acknowledge receipt of Tuomey Medical Professionals, Inc. s Notice of Privacy Practices. If not, why? DATE AND TIME SIGNATURE OF PATIENT or PERSONAL REPRESENTATIVE (Circle one: Parent, Guardian, or Legally Authorized Representative) Verification of Personal Representative by WITNESS (TMP Employee) HIPAA #1008A Consent and Conditions of Treatment

8

9

* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable)

* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable) Doctor: Patient Name: Address: State: Date of Birth: Home Phone: Work Phone: Zip: Patient Demographics Maiden Name: City: Social Security Number: Cell Phone: Email Address: * Do you wish to receive our

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

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

Patient Demographic Form

Patient Demographic Form Patient Demographic Form New Patient Returning Patient Primary Care Physician (PCP) Name: Patient Name: Last Name First Name MI Address: P.O. Box City: State: Zip: Cellular Number: Home Number: Work Number:

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

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

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

Patient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto

Patient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto For Office Use Updated By (Initial Here): Mailing Address: Patient Information City, State & Zip: Primary Home Cell Permission to Leave Messages: Yes No Secondary Home Cell Permission to Leave Messages:

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

Patient Financial Policies

Patient Financial Policies Patient Financial Policies Diabetes & Internal Medicine Associates, PLLC 2302 E. Terry St., Pocatello, ID 82301 208-235-5910 Fax 208-235-5920 Thank you for choosing Diabetes & Internal Medicine Associates,

More information

Patient Registration Form

Patient Registration Form 900 Carillon Parkway Suite 404 St. Petersburg, FL 33716 727-572-1333 727-572-1331 fax www.spencerdermatology.com Patient Registration Form Today s : Name: Suffix First Middle Last of Birth: / / Age: Sex:

More information

Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address:

Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address: Patient Demographics Name: _ of Birth: SS# Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Email: _ Home Address Insurance Information Insurance Provider: Group

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

Thank you for your cooperation.

Thank you for your cooperation. DR. RICHARD P. TOWNSEND M.D. VERONICA DEAN FNP-C Family Nurse Practitioner LAURA GRUNDY FNP-BC Family Nurse Practitioner Dr. Richard Townsend is a third generation physician. He was educated in Canada

More information

Updated as of 05/15/13-1 -

Updated as of 05/15/13-1 - Updated as of 05/15/13-1 - GENERAL OFFICE POLICIES Thank you for choosing the Quiroz Adult Medicine Clinic, PA (QAMC) as your health care provider. The following general office policies are provided to

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

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

Patient Registration Form (ecw) (First) (MI) Previous Name. Address

Patient Registration Form (ecw) (First) (MI) Previous Name. Address Patient Registration Form (ecw) PATIENT INFORMATION (Please Print) Dr. Miss Mr. Mrs. Ms. Patient's Name (Last) (First) (MI) Previous Name Address City, State ZIP Check the best contact number q Home Phone

More information

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

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

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider. Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best

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

Name: Location: Phone:

Name: Location: Phone: Welcome to our practice. Please complete all sections below. The signature of the patient, the custodial parent, or the legally responsible party is required. Please print all information. PATIENT INFORMATION:

More information

Behavioral Health Associates 6216 Airpark Drive Chattanooga, TN 37421

Behavioral Health Associates 6216 Airpark Drive Chattanooga, TN 37421 Welcome To Behavioral Health Associates Our mission is to help individuals, couples and families with their behavioral health goals. The set of documents to follow this page are explained below. Please

More information

Sincerely yours, Rev. 06.10

Sincerely yours, Rev. 06.10 Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy

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

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

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

Community Health Programs Patient Registration

Community Health Programs Patient Registration Community Health Programs Patient Registration Last Name: First Name: Preferred name: Middle Initial: Suffix: Gender: Male Female Former Last Name: Date of Birth: / / Social Security Number: SSN: Mailing

More information

California Pain Consultants - PATIENT REGISTRATION FORM

California Pain Consultants - PATIENT REGISTRATION FORM Patient Information California Pain Consultants - PATIENT REGISTRATION FORM First name: Last name: Middle Initial: Address: City, State, Zip Home phone :( ) -Work phone: ( ) -_Cell: ( ) - Birth Date: Age:

More information

The Orthopedic and Sports Medicine Institute Michael Boothby M.D. Richard Wilson M.D. Bret Beavers M.D. William J Shaw IV-PA-C Jeff Curtis PA-C

The Orthopedic and Sports Medicine Institute Michael Boothby M.D. Richard Wilson M.D. Bret Beavers M.D. William J Shaw IV-PA-C Jeff Curtis PA-C Today s Date: Patient Name: Last First Middle Initial Date of Birth: Age: Social Security Number: Gender: M F Preferred Phone: Secondary Phone: Home Address: City: State: Zip: Email Address: Employer:

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

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial) OFFICE POLICIES Thank you for choosing Spencer Dermatology and Skin Surgery Center for your health care needs. We recognize that you have a choice in health care providers and we appreciate the trust that

More information

RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number:

RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number: RETINA CONSULTANTS OF HOUSTON 6560 FANNIN, SUITE 750, HOUSTON TX 77030 PATIENT INFORMATION Patient's Legal Name: Date of Today's Visit: Social Security # Date of Birth: Age: Sex: M F Martial Status: S

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

I have received a copy of the Notice of Privacy Practices True Health.

I have received a copy of the Notice of Privacy Practices True Health. Sign-in Time: I have received a copy of the Notice of Privacy Practices True Health. Signature of Patient/Patient Representative Relationship of Patient Representative to Patient 2400 State Road 415 11881-A

More information

REGISTRATION FORM (Please print)

REGISTRATION FORM (Please print) REGISTRATION FORM (Please print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not so,

More information

Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury:

Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury: Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury: PATIENT INFORMATION First Name: Last Name: Date of Birth: Gender: Marital Status: S.S.N.

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

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

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed) Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.

More information

TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D.

TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D. TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D. PATIENT NAME: DOB: FINANCIAL and other OFFICE POLICIES Please be assured that everyone in this practice is dedicated to providing the highest quality medical

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

Patient Registration Form

Patient Registration Form PATIENT INFORMATION Patient Registration Form Date Patient Name (Last) (First) (Middle) Address City State Zip 911 Address (if different from above) Sex: M/F Birth date Age Social Security # Marital status:

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

Saratoga Cardiology Associates, PC 6 Care Lane Saratoga Springs, NY 12866 Phone: (518) 587-7625 Fax: (518) 587-0273

Saratoga Cardiology Associates, PC 6 Care Lane Saratoga Springs, NY 12866 Phone: (518) 587-7625 Fax: (518) 587-0273 Patient Name: DOB: Soc Sec#: Thank you for choosing Saratoga Cardiology for your cardiac care. We would like to welcome you to our practice. Please complete the attached form for our records and bring

More information

New Patient Packet. Marital Status: Single Married Divorced Separated Widowed Patient SSN: Address:

New Patient Packet. Marital Status: Single Married Divorced Separated Widowed Patient SSN:  Address: Patient Information New Patient Packet Patient First Name: Middle Initial: Last Name: Address: City: State: ZIP: Home Phone: Cell Phone: Work Phone: May we leave a voicemail? yes no May we leave a voicemail?

More information

Preferred Pharmacy: Phone: Fax:

Preferred Pharmacy: Phone: Fax: PATIENT INFORMATION: TODAY S DATE Last Name: Date of Birth: Sex: Male Female First Name: SS#: Middle Initial: Marital Status: Street Address: City: State: Home Phone: Work Phone: Mobile Phone: Email: Contact

More information

123 W. Washington St., Suite 321 Oswego, IL 60543 Phone: 630-383-2077

123 W. Washington St., Suite 321 Oswego, IL 60543 Phone: 630-383-2077 123 W. Washington St., Suite 321 Patient Information: : First Name: Middle Initial: Last Name: Address: City: State: Zip Code: S.S.#: Sex: Birth : Email Address: Primary Phone: (circle one) HOME CELL WORK

More information

The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME

The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME The McGregor Clinic Inc. Patient Registration/Demographic Form Patient Enrollment PLEASE USE LEGAL NAME First Name: MI: Last Name: of Birth: Sex: SS#: Marital Status: Single Married Separated Divorced

More information

Patient Registration Form

Patient Registration Form PATIENT INFORMATION Patient Registration Form Date Patient Name (Last) (First) (Middle) Address City State Zip 911 Address (if different from above) Sex: M/F Birth date Age Social Security # Marital status:

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

FAMILY PRACTICE PATIENT REGISTRATION FORM

FAMILY PRACTICE PATIENT REGISTRATION FORM FAMILY PRACTICE PATIENT REGISTRATION FORM **Today s Date: Clinic Name: Healthy Texan Pediatrics and Family Medicine PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: _ *First

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

Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - -

Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - - Appointment Information Date: Time: Physician: Patient Information Name: First MI Last Street Address Apt. or Post Office Box City State Zip Telephone Primary: ( ) Home Work Cell Work: ( ) Cell: ( ) Date

More information

(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _

(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 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

pain management AT GARDEN STATE MEDICAL CENTER

pain management AT GARDEN STATE MEDICAL CENTER pain management AT GARDEN STATE MEDICAL CENTER Dharam Mann, MD, DABA, DABPM Manjula Singh, MD Suhas Badarinath, MD, DABPMR Laurie Arsenakos, APN-C Dana Pratola, APN-C Specializing in Minimally-Invasive

More information

Community Health Programs Patient Registration. Last Name: First Name: Preferred Name: Zip Code: City: State:

Community Health Programs Patient Registration. Last Name: First Name: Preferred Name: Zip Code: City: State: Community Health Programs Patient Registration Last Name: First Name: Preferred Name: Middle Initial: Suffix: Former Last Name: Gender: Male Female Date of Birth: / / Social Security Number: Mailing Address:

More information

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C. LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME

More information

OFFICE POLICIES, EFFECTIVE October 19, 2009

OFFICE POLICIES, EFFECTIVE October 19, 2009 Thank you for choosing our office for your medical care. We have written these policies to keep you informed of our current office policies. Please refer to our website for policy updates. OFFICE POLICIES,

More information

Quiroz Adult Medicine Clinic, P.A. General Office Policies

Quiroz Adult Medicine Clinic, P.A. General Office Policies General Office Policies Thank you for choosing Quiroz Adult Medicine Clinic P.A. (QAMC) as your health care provider. The following general office policies are provided to understand our office protocols

More information

Nova Medical & Urgent Care Center, Inc Financial Policy

Nova Medical & Urgent Care Center, Inc Financial Policy Welcome and thank you for choosing Nova Medical & Urgent Care Center, Inc (hereafter referred to as Nova ) for your medical care. We are committed to providing you with the highest quality medical care

More information

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS

More information

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470 PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone

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

PATIENT DEMOGRAPHIC INFORMATION FORM

PATIENT DEMOGRAPHIC INFORMATION FORM If you did not complete these forms in advance and bring them with your initial appointment today, then please complete them, and sign them now. Our office does not receive email from patients. We do use

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

2015 Annual Patient Paperwork Update for Existing Patients

2015 Annual Patient Paperwork Update for Existing Patients 2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě

More information

Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.

Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card. Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful

More information

Welcome TO THE PRACTICE

Welcome TO THE PRACTICE Welcome TO THE PRACTICE Patient Information Date Name Birthdate SS# Address City/State Zip Code Driver s License # Name of Employer Check appropriate box Minor Single Married Divorced Widowed Contact Numbers

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

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician)

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Date: To: Fax: Please, release a copy of medical records for the following patient(s):

More information

THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465

THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465 THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465 Dear Patient: Welcome to the Eye Institute. Our mission is to provide you with the highest

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

How do you prefer to be reminded of your dental appointments?

How do you prefer to be reminded of your dental appointments? PATIENT REGISTRATION DATE: ADULT PATIENT CHILD PATIENT Name Address City State Zip Email Landline Cell Phone Do you work? Where? Work Phone Date of Birth Social Security # Single Married Divorced Widowed

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

11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509

11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509 PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED

More information

Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine

Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth Social Security # Male / Female Race Ethnicity (Latino / Non Latino)

More information

License Number: Occupation:

License Number: Occupation: P a g e 1 Today s Appt : Time: Physician: Patient s Name of Birth: Age: Address: Home Phone: Business Phone Cell Phone Sex Social Security: Marital Status License Number: Occupation: Who is your Primary

More 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

LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net

LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first appointment at our office on

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

5044 Tennyson Parkway Suite B Plano, TX 75024 Phone 972-985-9003 Fax 972-985-1176. Welcome to The Center for Dermatology and Cosmetic Laser Surgery!

5044 Tennyson Parkway Suite B Plano, TX 75024 Phone 972-985-9003 Fax 972-985-1176. Welcome to The Center for Dermatology and Cosmetic Laser Surgery! Center for Dermatology & Cosmetic Laser Surgery Bryan A. Selkin MD Michael Wells MD Gilbert Selkin MD, DMD Angel Puryear MD Mara Dacso MD, MS Ami Bhattacharya PA-C Hope Thibodeaux PA-C Lauren Hughes PA-C

More information

105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556

105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556 105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556 Scott Fowler, MD, FACOOG Chad Jarjoura, MD, FACOG Renda Knapp, MD, FACOG Christopher Mitchell, MD, FACOG Daphne

More information

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: INSURANCE INFORMATION Did you injure yourself at work or is this injury a

More information

Patient Demographic Form

Patient Demographic Form Patient Demographic Form Today s Date This document is part of your permanent record. By law, we are required to collect the following information from every patient treated in our facility. Please assist

More information

PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015

PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015 Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PATIENT FINANCIAL POLICIES Effective Date: June

More information

PATIENT REGISTRATION FORM. Demographic Information For Office Use Only

PATIENT REGISTRATION FORM. Demographic Information For Office Use Only PATIENT REGISTRATION FORM I ll review the Welcome Packet online at www.thwcinc.com OR I d like a copy of the Welcome Packet to review while waiting Section I I want Online Access to my Medical Records

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

Athens Neuro & Balance Rehabilitation

Athens Neuro & Balance Rehabilitation Acknowledgement of Receipt Of Notice of Privacy Practices Patient Name & Address: I have a received a copy of the Notice of Privacy Practices for the above named practice. Signature For Office Use Only

More information

UPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth:

UPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth: COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors UPDATE FORM 2011 Please fill out this form completely (front and back) Name: (First) (Last) (Middle

More 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

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

Advanced Solutions Pain Management

Advanced Solutions Pain Management Joseph Ho, M.D. Sabrina Shue, M.D. Patient Information Name: M F Age: Last, First, Middle (Circle One) DOB: SSN: Single Married Divorced Separated Widowed Address: City: State: Zip: Home Phone: Cell: Work:

More information

Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900

Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900 PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip

More information

FURMAN UNIVERSITY SPORTSMEDICINE CENTER

FURMAN UNIVERSITY SPORTSMEDICINE CENTER IMPORTANT INSURANCE INFORMATION Dear Parents: Furman University provides an excess coverage policy for our intercollegiate athletes. Incurred medical charges are to be filed with your insurance first.

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

Agnes Ju Chang, M.D., F.A.A.D.

Agnes Ju Chang, M.D., F.A.A.D. Agnes Ju Chang, M.D., F.A.A.D. Dear Valued Patient: Thank you for choosing Integrated Dermatology of K Street, the office of board certified dermatologists, Dr. Agnes Ju Chang, Dr. David A. Lee, Allison

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