HSE Medical Associates Family Practice

Size: px
Start display at page:

Download "HSE Medical Associates Family Practice"

Transcription

1 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. Lindsey Havel, P.A. Elizabeth Grizzaffi, P.A. Jessica Alayon, How did you hear about us? All questions must be answered completely. If you need assistance, please see the receptionist. PLEASE PRINT CLEARLY PATIENT INFORMATION: Last Name: First Name: Middle Initial: Address: Apt #: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Sex: Male Female Marital Status: M S D W NA Student Status: FT PT ****Please provide us with your insurance card(s) at the time of your visit**** Relationship of Patient to the Policy Holder Self Spouse Child Other please specify POLICY HOLDER INFORMATION: Primary Insurance: Last Name: First Name: Middle Initial: Address: Apt #: City: State: Zip Code:

2 Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: HSE Medical Associates Family Practice GUARDIAN INFORMATION Person responsible for the bill: Please fill out only if the person responsible for the patient bill is different from the policy holder s information or the patient s information. Last Name: First Name: Middle Initial: Address: Apt #: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: ASSIGNMENT OF INSURANCE AND AUTHORIZATION TO RELEASE INFORMATION I hereby authorize my current insurance company to pay directly to HSE Medical Associates benefits due me, if any, by reason of sercives described in the statement rendered and are provided for the above policy contact with the above mentioned insurance company. I will be responsible for all such charges incurred in excess of whatever sum may be paid by my insurance company. Signature: Date: MEDICARE CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, PAYMENT REQUEST I request that payment of authorized Medicare benefits be made, whether to me or on my behalf to HSE Medical Associates, for any services provided to me by the physicians. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. Signature: Date:

3 HSE Medical Associates Family Practice PATIENT PRIVACY RIGHTS UNDER THE Health Insurance Portability and Accountability Act of 1996 (HIPPA), all patients have certain rights to privacy regarding health information. This protected information can and will be used to: Conduct, plan and direct treatment and follow up among the multiple healthcare providers who may be involved directly and indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. Patients may request, in writing, to restrict how private information is used or disclosed to carry out treatment, payment or healthcare operations. Though not required to agree to requested restrictions, we are bound to abide by agreed upon restrictions. Patients may revoke consent at any time, except to the extent that action has been taken relying on prior consent. The following page is a detailed consent form to allow/disallow any person whom you may want/not want to obtain private health information. By signing below you acknowledge that you understand that HSE Medical Associates is allowed to release/not release health information specific to your request. Patient Name (please print): Signature: Today s date:

4 HSE Medical Associates Family Practice CONSENT FOR DISCLOSURE TO FAMILY MEMBERS AND/OR PERSONAL REPRESENTATIVE CONDITIONS FOR DISCLOSURE: It is often difficult to talk to patients in person. Therefore, we must have your permission as to how we may communicate with you. Please check if you AGREE to the following conditions: HSE Medical Associates may disclose my medical information to me and to the following individual(s) in my presence and when I am not physically present, including disclosures by telephone, voice mail, fax, or mail. I have agreed to let certain individuals participate in discussions and decisions related to my medical care. Therefore, I hereby give my permission for HSE Medical Associates to disclose my personal medical information to the following individuals: Name: Relationship: Name: Relationship: Name: Relationship: If you DO NOT AGREE, please check below: I do not wish for HSE Medical Associates to disclose any of my medical information to anyone other than myself.

5 I understand that this consent may be revoked by me at any time, in writing, to HSE Medical Associates. Patient Name (please print): Patient Signature: Today s Date: We at HSE Medical Associates, are dedicated to providing the best possible medical care and service to you and your family. Your understanding of our financial responsibility policy is an essential element of your care and service. With all the new healthcare changes, we have updated our policies. This will prevent any misunderstandings and allow us to serve you better. FINANCIAL and BILLING POLICIES (Please read and initial EACH item below): 1) You are ultimately responsible for knowing what your plan does and does not cover, and the administrative rules. (i.e.: in-network/out of network: out of pocket balance, copayment, coinsurance, deductible, Health-Savings Account balances; labs/radiology/ekg; prior authorizations and referrals) 2) Each patient is encouraged to verify if specific labs/other procedures are covered or not covered (i.e.: preventive benefits & screenings such as EKG/XRays/MRI/CT and immunizations, as well as mental health office visits). Also, the percentage that each procedure or lab is covered at, such as 100%, 80%, 70% etc. 3) As a courtesy, we will verify your eligibility and benefits. However, we cannot guarantee that the information received is accurate due to insurance policy changes and real-time/up-to-date system information. We will bill your insurance company with whom we have a contract agreement. 4) Once your benefits have been determined, payments of any copays, coinsurance, deductible and fees are required at the time services are rendered. 5) Once your insurance company has processed a claim, any balance as determined by your insurance plan to be patients responsibility and/or non-covered service, will be your responsibility. 6) If you disagree with the patient responsibility amounts due to our office per your insurance s Explanation of Benefits (EOB), please immediately call your insurance company and our office for further explanation. 7) Failure to provide current insurance information to our office and/or reply back to insurance s request for additional information may result in the entire bill being your responsibility. 8) Self Pay patients: Full payment for your visit is expected on the day of the visit. 9) Any outstanding balance owed to our office is also due, unless payment arrangements have been made in advance with our office. 10) The independent labs (Quest Diagnostics, LabCorp, and North Cypress Medical Center) will also bill independently. If you receive a bill from the lab, you will need to contact the lab for further detail and payment arrangement. 11) There will be a fee for ALL forms to be filled out and/or typed letters requiring a signature from our physicians, nurse practitioners, physician assistants or any medical staff. There is also a charge for re-writing lost prescriptions. 12) Our office DOES NOT bill third parties (i.e.: automobile insurance). Your visit will be self-pay and a receipt will be given to you to file with your auto insurance. Our office DOES NOT accept workman s compensation cases. 13) Please notify us in advance if you cannot keep your appointment. We reserve the right to ask you to seek care from another physician if you miss three appointments without notification. If you are more than 30 minutes late for your appointment, you may be asked to reschedule.

6 14) There will be a $25 charge for ALL RETURNED CHECKS. GENERAL MEDICATION REFILL POLICIES: For medication refills, please call the pharmacy and speak to a technician/person. Allow at least one week left on current medication when calling the pharmacy for a refill. Allow at least 48 hours after we receive the refill request from the pharmacy to process the request. Refills will not be processed as an emergency. Please plan ahead. Patient is responsible for keeping track of the amount of medication remaining, and for taking the medication as prescribed. No refills will be made during weekends or holidays. ****Some medications require closer monitoring than others. A general outline is as follows**** Mental health medications require an appointment every 3 6 months based on individual assessment. Narcotics require an appointment for every refill. THERE ARE NO EXCEPTIONS. Triplicate prescriptions require an appointment every 3 6 months (or sooner if changes are needed). All other maintenance medications require a 3 6 month follow up appointment for consideration on therapeutic regimen and necessary blood work. It is per the discretion of the physician if an appointment will be required before a refill is granted. Many factors and circumstances are considered before a final decision is made. Thank you. Patient Name (please print) Last First Signature: Date of Birth: Date: If patient is a minor, please PRINT parent/guardian name: Things My Doctor/Provider Should Know H S E P Lindsey Darcy Elizabeth Jessica - Please circle your providers name or initial NAME: DOB: / / Personal Medical History: Please indicate whether you have had any of the following medical problems (with approximate date of illness/diagnosis): Congenital Heart Disease Coagulation/bleeding Disorder Problems: Other (Specify type) Cancer Heart Attack (Specify type) Diabetes Depression/suicide attempt High Cholesterol Alcohlism Stroke Blood Transfusion Thyroid Disease (Specify date) Date of last Tetanus Vaccine: (Specify type) Abnormal Pap Smear Past Surgical History: Please list dates of all operations with dates. Social History: Marital Status - Married Divorced Single Widowed Occupation: (circle one) Separated Co-Habitating Engaged Tobacco: Cigarettes Cigars Dip/Snuff Pipe Spouse/Partner's Name: How much?

7 Number of children: Alcohol: Yes No # drinks/week: Who lives at home with you? Drugs: Yes No Family History: Please indicate with check ( ) family members who have had any of the following conditions: High BP High Cholesterol Heart Attack Stroke Diabetes Thyroid Disease Cancer Type? Father Mother Brother Sister Child Grandparent Other How did you hear about us? Referred by friend/patient Ad ER Other Please see other side to list your medications and provide the name of other specialists Updates --- HSE Medical Associates NAME: DOB: / / Please list all of your current medications/doses (including over-the-counter & supplements): Any reactions/allergies to medications? Since your last visit - have you seen any new doctors/specialists? Yes No Please list all your current doctors/specialists:

8 Any new medical conditions/diagnoses? Yes No (over) Date MEDICAL PERMISSION TO TREAT MINOR CHILD To whom it may concern: Regarding (Give full Name of Child and Date of Birth) As the parents of the above-named child, (Name of Responsible Adult) has my permission to seek medical treatment for this child. From to or Date Date Indefinitely (Signature) (Parent Name)

9 (Cell Phone) (Work Phone) (Home Phone)

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

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

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

AUTHORIZATION OF USE/ DISCLOSURE OF PROTECTED INFORMATION OK TO SEND TEXT MESSAGE AND S - (CIRCLE ONE) YES OR NO

AUTHORIZATION OF USE/ DISCLOSURE OF PROTECTED INFORMATION OK TO SEND TEXT MESSAGE AND  S - (CIRCLE ONE) YES OR NO Amy C. Murphy, M.D. Kyle K. Carter, M.D. John W. Bailey, M.D. 1428 W. Hebron Parkway, Ste 110, Carrollton, Texas 75010 Phone 972-939-4555 Fax 972-939-7020 AUTHORIZATION OF USE/ DISCLOSURE OF PROTECTED

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

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

Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip

Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip Klein & Associates, M.D., P.A. Registration Form Patient s Last Name First MI Social Security # Date of Birth Age Sex M F Family Referring Doctor Doctor Home Address Apt # City State Zip Home Phone ( )

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

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

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

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

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

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

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

(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

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

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

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

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

New Beginnings Wellness Center & Spa 927 N. Trenton Street Ruston, LA PH FAX. New Patient CHILD

New Beginnings Wellness Center & Spa 927 N. Trenton Street Ruston, LA PH FAX. New Patient CHILD PATIENT INFORMATION Last Name: First Name: MI: DOB: Female Male Home Address: City: State: Zip: Billing Address: City: State: Zip: Phone 1: ( ) Home Work Cell Phone 2: ( ) Home Work Cell Social Security

More information

Welcome to New Image Dermatology!

Welcome to New Image Dermatology! Welcome to New Image Dermatology! We are pleased that you have chosen New Image Dermatology for your dermatologic care. We are dedicated to providing our valued patients with outstanding medical care.

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

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

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 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

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

Corridor Primary Care Pediatrics 601B Leah Avenue San Marcos, TX Phone: (512) Fax: (512)

Corridor Primary Care Pediatrics 601B Leah Avenue San Marcos, TX Phone: (512) Fax: (512) Patient Information Corridor Primary Care Pediatrics Phone: (512) 392-1700 Fax: (512) 396-8743 Patient s Name: Age: DOB: Gender: Male Female Race: African-American White/Hispanic Asian Other: Address:

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 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

CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork

CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork New Patient Paperwork NAME OF PATIENT ( ) MALE ( ) FEMALE ADDRESS APT CITY STATE ZIP HOME PHONE # CELL PHONE # DATE OF BIRTH AGE SOCIAL SECURITY # MARITAL STATUS E-MAIL ADDERSS OCCUPATION EMPLOYER EMPLOYER

More information

CONSENT FOR MEDICAL TREATMENT

CONSENT FOR MEDICAL TREATMENT CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern

More 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

Welcome to Tri-State Rehab Services

Welcome to Tri-State Rehab Services Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely

More 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

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

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

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

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

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

Medical History Questionnaire

Medical History Questionnaire Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of

More information

Sign(Patient or Guardian) Please complete all the information below in print, please do not leave any questions blank. Thank You!

Sign(Patient or Guardian) Please complete all the information below in print, please do not leave any questions blank. Thank You! Please complete all the information below in print, please do not leave any questions blank. Thank You! I hereby authorize payment directly to the business office of this physician/clinic for surgical

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

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

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: ( Eye Consultants of Atlanta, P.C. Scottish Rite Office 5445 Meridian Mark Road, Suite 220, Atlanta, GA 30342 Phone: (404-255-2419) - Fax (404-255-3101) Zane Pollard, M.D. Marc F. Greenberg, M.D. Mark A.

More information

7312 East Deer Valley Road, Suite PATIENT INFORMATION

7312 East Deer Valley Road, Suite PATIENT INFORMATION PROVIDER: KRIS DINUCCCI 7312 East Deer Valley Road, Suite 110 480.342.9999 Scottsdale, Arizona 85255 www.arizonafoot.com NAME: DATE OF BIRTH: HOME ADDRESS: BILLING ADDRESS (IF DIFFERENT): PREFERRED PHONE

More information

BLUE RIDGE DERMATOLOGY, PC CHARLES R. PAULY, MD CYNTHIA H. DENT, MD KEITH A. KNOELL, MD JANE M. LYNCH, MD

BLUE RIDGE DERMATOLOGY, PC CHARLES R. PAULY, MD CYNTHIA H. DENT, MD KEITH A. KNOELL, MD JANE M. LYNCH, MD BLUE RIDGE DERMATOLOGY, PC CHARLES R. PAULY, MD CYNTHIA H. DENT, MD KEITH A. KNOELL, MD JANE M. LYNCH, MD PAUL A. KRUSINSKI, MD INES W. SOUKOULIS, MD PATIENT INFORMATION PLEASE PRINT NAME (LAST) (FIRST)

More information

Leah McNeill, ND Debbie Swanson, ND Ohana Wellness Center th Ave NE Suite D-200 Bellevue, WA 98005

Leah McNeill, ND Debbie Swanson, ND Ohana Wellness Center th Ave NE Suite D-200 Bellevue, WA 98005 Leah McNeill, ND Debbie Swanson, ND Ohana Wellness Center 2340 130th Ave NE Suite D-200 Bellevue, WA 98005 (Please print clearly) PATIENT INFORMATION Name: Birth Date: / / Sex: M F Marital Status (circle

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

Welcome to our office: New Patient Paperwork: Co-Pays and Deductibles: Insurance information: Prescription Refills: Medical Records Request:

Welcome to our office: New Patient Paperwork: Co-Pays and Deductibles: Insurance information: Prescription Refills: Medical Records Request: 9330 Poppy Dr. Suite 400 Dallas, TX. 75218 Phone: (469) 619-2897 Fax: (972) 412-7383 Welcome to our office: Thank you for choosing our practice and allowing us to take part in your medical care. It is

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

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

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp

More information

1 5 0 K E N N E D Y D R I V E S O U T H B U R L I N G T O N, V E R M O N T 0 5 4 0 3 8 0 2 4 4 8 9 3 7 0 8 0 2 4 4 8 1 4 1 4 (F)

1 5 0 K E N N E D Y D R I V E S O U T H B U R L I N G T O N, V E R M O N T 0 5 4 0 3 8 0 2 4 4 8 9 3 7 0 8 0 2 4 4 8 1 4 1 4 (F) Worker s Compensation Intake Form : Name: DOB: Social Security Address: City ST Zip Home Phone: Alternate Phone: Occupation: Employer Name: Employer Contact: Do you see a primary care physician for your

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

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

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

WELLS PHYSICAL THERAPY SERVICES PATIENT INFORMATION 175 Wilson Rd. Suite 101 Middlebury, VT

WELLS PHYSICAL THERAPY SERVICES PATIENT INFORMATION 175 Wilson Rd. Suite 101 Middlebury, VT WELLS PHYSICAL THERAPY SERVICES PATIENT INFORMATION 175 Wilson Rd. Suite 101 Middlebury, VT 05753 802-388-3533 Name: Last First M.I. Social Security Number: Marital Status: (please circle) Married Single

More information

Patient Signature/Guardian Signature

Patient Signature/Guardian Signature Purvisha Patel, M.D., FAAD, FASDS Board-Certified Dermatologist/Fellowship-Trained Mohs & Cosmetic Surgeon Patient Name:,, Last Name First Name Middle Initial Address:, Marital Status: Married Single Divorced

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

Westmoreland Dermatology & Surgery Center

Westmoreland Dermatology & Surgery Center Westmoreland Dermatology & Surgery Center Patient Information Patient s Legal Name: (First, Middle, Last) Marital Status: Gender: Divorced Married Male SSN: of Birth: Single Minor Female Language: Ethnicity:

More information

New York Ophthalmology, P.C.

New York Ophthalmology, P.C. New York Ophthalmology, P.C. Dear Patient, Ophthalmology * PLEASE PRINT ON SINGLE SIDED, WHITE PAPER * Opthalmic Surgery Optometry * PLEASE USE BLACK INK ON ALL FORMS * Cornea External Disease Laser Vision

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

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

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

Healthy Living Clinic, LLC Phone:(321) 549-2273/ FAX:(321) 549-2066

Healthy Living Clinic, LLC Phone:(321) 549-2273/ FAX:(321) 549-2066 IDENTIFYING INFORMATION Patient Enrollment Form PATIENT NAME: SEX: MALE FEMALE DOB: / / SS# -- -- MO DAY YEAR CONTACT HOME PHONE: EMAIL: WORK PHONE: Preferred method of communication Email Mail Home Phone

More information

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

When you arrive for your first appointment, please bring the following with you: 115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your

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

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

Welcome and thank you for choosing eriver Neurology of New York, LLC Phone: (845) 452-9750 Fax: (845) 452-9751. Office Policies

Welcome and thank you for choosing eriver Neurology of New York, LLC Phone: (845) 452-9750 Fax: (845) 452-9751. Office Policies Welcome and thank you for choosing eriver Neurology of New York, LLC Phone: (845) 452-9750 Fax: (845) 452-9751 eriver Neurology of New York, LLC does not discriminate against any person on the basis of

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

OB-GYN Associates, P.A.

OB-GYN Associates, P.A. Physician PATIENT INFORMATION Patient Name (First, M.I., Last) Social Security # Date of Birth Marital Status Address - - / / Apt # - Lot # - Bldg # - C/O City State Zip Code Home Phone Who referred you

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

METROPOLITAN EYE CARE Scott B. Pomerantz, M.D., Thomas J, LoPresti, O.D. 523 Forest Avenue Paramus, NJ 07652 (201) 262-5070

METROPOLITAN EYE CARE Scott B. Pomerantz, M.D., Thomas J, LoPresti, O.D. 523 Forest Avenue Paramus, NJ 07652 (201) 262-5070 METROPOLITAN EYE CARE Scott B. Pomerantz, M.D., Thomas J, LoPresti, O.D. 523 Forest Avenue Paramus, NJ 07652 (201) 262-5070 Please complete and sign where indicated Patient Information: Last Name: First

More information

Orthopedic Specialty Associates, P.A.

Orthopedic Specialty Associates, P.A. Orthopedic Specialty Associates, P.A. TEL 817.878.5300 FAX 817.878.5307 Keith C. Watson, M.D. Reconstructive Surgery of the Shoulder and Elbow John E. Conway, M.D. Reconstructive Surgery of the Shoulder,

More information

Next Level Physical Therapy PC Patient Information

Next Level Physical Therapy PC Patient Information Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home

More information

Patient Name: D.O.B. Age: (Last) (First) (Middle) Physical Street Address: Mailing Street Address: City: State: Zip Code:

Patient Name: D.O.B. Age: (Last) (First) (Middle) Physical Street Address: Mailing Street Address: City: State: Zip Code: Patient Name: D.O.B. Age: (Last) (First) (Middle) Physical Street Address: Mailing Street Address: City: State: Zip Code: Social Security Number: - - Marital Status: Sex: Home Phone: ( ) Work Phone: (

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

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

Primary Care Internal Medicine in Evans

Primary Care Internal Medicine in Evans Zhenrong Zhang, M. D. Thank you for choosing Primary Care. We are delighted to welcome you and will make every effort to serve you in a manner that will meet your expectations. Please assist us by completing

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

Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com

Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com 1 Calvin E. Mein, MD 9480 Huebner Rd, Suite 310 (210) 615-1311 Moises A. Chica, MD San Antonio,

More information

Your appointment is scheduled for:

Your appointment is scheduled for: 14090 H.G. Trueman Road, Suite 1400 Solomons, MD 20688 410-610- 2246 Rebecca L Jahed, AuD, FAAA Welcome to Freedom Hearing Center. My name is Dr. Rebecca L. Jahed and I am the President of this private

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

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

* 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

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

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

PATIENT/PARENT/GUARDIAN SIGNATURE

PATIENT/PARENT/GUARDIAN SIGNATURE PATIENT REGISTRATION PATIENT S NAME: SEX MALE FEMALE DOB: SOCIAL SECURITY #: CITY/STATE/ZIP: PHONE # GUARANTOR INFORMATION (if responsible party is not the patient) MOTHER S NAME: DOB: SS#: CITY/STATE/ZIP:

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

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

Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11

Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11 PATIENT REGISTRATION 3.11 Last Name: First Name: MI: Local Address: City: State: Zip Code: DOB: Sex: Marital Status: Race: SSN [Required for reporting to Agency for Health Care Administration]: Were you

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

PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT

PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex:

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

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 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

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

PATIENT REGISTRATION

PATIENT REGISTRATION PATIENT REGISTRATION NAME: HOME ADDRESS: CITY, STATE, & ZIP CODE: HOME PHONE: CELL: WORK: SOCIAL SECURITY NUMBER: SEX: MALE/FEMALE DATE OF BIRTH: AGE: EMERGENCY CONTACT: RELATIONSHIP: EMERGENCY CONTACT

More information

NEW PATIENT REGISTRATION FORM

NEW PATIENT REGISTRATION FORM Last Name: First Name: MI: Date: DOB: Age: Gender: Female / Male Race: Ethnicity Language Marital Status (please circle): Married / Single / Divorced/Widowed Address: Home Phone # City: State: Zip Code:

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