IS THIS PROBLEM WORK RELATED?
|
|
- April Summers
- 8 years ago
- Views:
Transcription
1 PATIENT NAME: (Last) (First) (Middle) Female Male Birth Date: Age: Social Security No: Single Married Widowed Divorced Mailing Address: (City) (State) (Zip) ok to leave a message Yes No Preferred Phone: ok to leave a message Yes No ***By signing this document, I am giving Tri City Orthopaedic Clinic permission to contact me on all phone numbers listed. Ethnicity: Caucasian Hispanic/Latino Asian American Indian/Alaskan Native Black/African American Native Hawaiian/Other Pacific Islander Decline Language: English Spanish Russian Other Interpreter Service: Employed Unemployed Full Time Student Retired Disabled Employer: Phone: Referring Source (i.e. Doctor, TV, Newspaper, Friend): Reason For Visit (List Body Part): Left Right Person Responsible For Payment: (if patient is a minor under 18): (Last) (First) (Middle) Female Male Birth Date: Age: Social Security No: Mailing Address: (City) (State) (Zip) Employer: IS THIS PROBLEM WORK RELATED? Yes No Employer at the time of injury: Injury Date: Claim Number: Claim Manager: Last date worked: Industrial Insurance Carrier: Insurance Carrier Address: (City) (State) (Zip) Phone: Is the Claim Currently Open: Yes No If Not, When Did the Claim Close? IS THIS PROBLEM THE RESULT OF A MOTOR VEHICLE ACCIDENT? Yes No Date of Accident: State Accident Occurred: Claim Number: Claim Manager: Phone: MVA Insurance: MVA Insurance Address: (City) (State) (Zip) Phone: OVER
2 Primary Medical Insurance: Effective Date: Subscriber ID #: Group #: Copay: Subscriber Subscriber Birth Date: Social Security No: Subscriber Address: Mailing Address: (City) (State) (Zip) Subscriber Employer: Secondary Medical Insurance: Effective Date: Subscriber ID #: Group #: Copay: Subscriber Subscriber Birth Date: Social Security No: Subscriber Address: Mailing Address: (City) (State) (Zip) Subscriber Employer: Tertiary Medical Insurance: Effective Date: Subscriber ID #: Group #: Copay: Subscriber Subscriber Birth Date: Social Security No: Subscriber Address: Mailing Address: (City) (State) (Zip) Subscriber Employer: Emergency Contact: (Last) (First) (Middle) Birth Date: I have completed the above information to the best of my knowledge. I request that payment of authorized benefits be made to me or on my behalf to Tri City Orthopaedic Clinic for any services furnished to me. I authorize Tri City Orthopaedic Clinic to release any medical information which may be requested to determine benefits through my above named insurance carrier. I understand that if any insurance does not pay in full for services provided by Tri City Orthopaedic Clinic, I assume liability for the unpaid portion. This agreement shall be governed and enforced in accordance with the laws of the State of Washington. X Signature of Authorized Person Date Relation Created: 4/5/2012 Edited: 12/5/13
3 6703 W Rio Grande Ave. 821 Swift Blvd. 965 Goethals Dr. Kennewick, WA Richland, WA Richland, WA Ph: (509) Ph: (509) Ph: (509) Fax: (509) Fax: (509) Fax: (509) Office Policies for Tri-City Orthopaedic Clinic Patient Information: You are required to provide photo identification at each visit along with any current insurance information. Please notify the receptionist when you have any changes to the following: Address, phone (work, cell or home), insurance. Co-pays/Deductibles/Co-insurances: If your insurance requires any of the above, you will be asked to pay this at the time of service. For your convenience we accept cash, check, debit/credit cards (Visa, MasterCard, Discover and American Express). If you are unable to pay these at time of service you agree to a $20 fee to be added to your bill. Prior Balances: Prior balances must be paid within 30 days unless a signed payment plan has been executed. Self Pay: We ask that payment be made in full at the time of service unless prior arrangements have been made with the Patient Account Representative. We accept cash, debit and/or credit cards (Visa, MasterCard, Discover and American Express). If we are an out of network provider with your insurance company and you do not have out of network benefits, then you will be considered a cash pay patient and agree to the cash pay policy above. Reminder Calls: As a courtesy you will receive an automated reminder call for your scheduled appointment. We ask if you are unable to make this appointment to notify us as soon as possible. Ultimately it is your responsibility to remember your appointment time and date. Cancelled or Missed Appointments: We will do everything possible to make sure that your appointment is on schedule. Patients arriving more than 15 minutes late may not be seen. New patients who do not arrive early enough to complete paperwork before their appointment may need to be rescheduled. No Shows: If you are unable to show up for a scheduled appointment we require a phone call 24 hours (not including weekends) in advance. If an emergency arises and you need to call and cancel an appointment with less than 24 hours notice, please let the receptionist know the reason for your cancellation. If this is not done the cancellation may be designated as a No Show. After three (3) No Show appointments, TCO may discharge you from the clinic. Insurance: Many people are under the impression that if they have insurance, it is the insurance company that owes TCO for your services. This is NOT the case. TCO bills your insurance as a courtesy. The insurance contract is between you and the insurance company. If your insurance does not pay TCO please contact the billing department to make payment arrangements. Revised: 03/24/2014 Created: 03/19/2013
4 Workman s Compensations/Motor Vehicle Accidents: All information has to be provided prior to scheduling the appointment in order to verify claim is open and allowed or that Personal Injury Protection is not exhausted or your appointment may be rescheduled. If no private insurance is available and we are unable to verify an open claim, there is a mandatory $ deposit required at time of service in the form of cash/check/credit/debit/money order. Once we verify a claim is open and allowed, we will refund any money owing on the claim (refer to Refund policy). Prescription Refills: We require hours notice on all refills. Refill requests accepted during office hours only, as posted, or online via our website. Any prescription refill requests need to go thru your pharmacy. Request a fax to be sent to our office for the refill. Due to our surgery schedules, the physicians are not always available to sign medication requests. Forms and/or Paperwork Fee: There is a $15.00 fee for the completion of a form or paperwork. We require 7-10 working business days to complete both. Bankruptcy: If you have previously declared bankruptcy within our clinic, you will be required to sign a Bankruptcy Contract. There is a $75.00 deposit prior to each visit in the form of cash/credit/debit/money order. After each visit, your patient responsibility will be calculated and the deposit will be applied, any additional amount owing will be collected at this time. Any refund will be processed at this time. As a courtesy we will bill your insurance. Collection: If you have previously been sent to collections, you will be required to sign a Collection Contract. There is a $75.00 deposit prior to each visit in the form of cash/credit/debit/money order. After each visit, your patient responsibility will be calculated and the deposit will be applied, any additional amount owing will be collected at this time. Any refund will be processed at this time. As a courtesy we will bill your insurance. Refund: If you feel you have a credit on your account, please contact the Billing Department. If all your care is completed and all services have been paid a refund will be issued within two (2) weeks after an account audit has been conducted. Even if no request has been made account audits are regularly conducted and any refund owing will be issued once audit is completed. I have read and agree to the above. Further, I agree that if I fail to abide by these policies I may be discharged from the clinic. Patient Name (Print) Date of Birth Patient Signature/Signature of Authorized Person Date Revised: 03/24/2014 Created: 03/19/2013
5 6703 W Rio Grande Ave 821 Swift Blvd 965 Goethals Dr Kennewick, WA Richland, WA Richland, WA Ph: (509) Ph: (509) Ph: (509) Fax: (509) Fax: (509) Fax: (509) CONSENT FOR USE AND DISCLOSURE OF PRIVATE HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS Patient Name: Date of Birth SSN: Previous Name (if any) My health information is a private matter. Tri-City Orthopaedic Clinic, PSC has a form that can tell me how his clinic handles my health care information. This form is entitled Notice of Privacy Practices. If I ask, Tri-City Orthopaedic Clinic, PSC will provide me with the most current Notice before I sign this consent. I understand that the clinic may update this Notice at any time and that if I request it, I will receive a current copy of the Notice. I agree that Tri-City Orthopaedic Clinic, PSC may use and disclose my health information to help treat me, for insurance and billing related to my physician visits and for other health care operations such as appointment reminders, calling with results of laboratory tests and performing health quality improvements in the practice. I also understand that the law sometimes requires the release of health care information without my approval such as in cases of child abuse or neglect. I may ask Tri-City Orthopaedic Clinic, PSC to further limit the use or disclosure of my health information and that I must do this in writing. The clinic is not required to agree to my request but will usually attempt to meet my restrictions. I may cancel this consent at any time, by doing one of the following: Signing and dating a revocation form. I may get this form from the clinic; Writing, signing and dating a letter to Tri-City Orthopaedic Clinic, PSC which says that I cancel my consent to authorize the use and disclosure of my health care information for treatment, payment and health care operations. If I cancel this consent: It will be effective except for actions already taken based upon the Consent: and Tri-City Orthopaedic Clinic, PSC will not have to provide any more health care services to me. I have been given the chance to read a current copy of Tri-City Orthopaedic Clinic, PSC s Notice of Privacy Practices. I agree to allow Tri-City Orthopaedic Clinic, PSC to use and disclose my health information to carry out treatment, payment and health care operations. (Patient or legally authorized signature) Revised: 8/7/13 Created: 4/5/12 Date OVER
6 Consent To Inform Your Right to Privacy ** PLEASE PRINT** PATIENT S NAME: We respect your right to privacy regarding medical information. Without additional written consent, may share information with your spouse? If yes, their name: We understand you may have concerned relatives. Please list the names of adults, children, other family members and/or contact persons with whom we may share information, without additional written consent, and their relationship to the patient: Check if N/A (not applicable): ** If there are any changes to be made on this form it is the patient s responsibility to let us know at each occurrence. Signature of patient or patient s authorized representative Date: Relationship or status if signed by anyone other than patient (parent, legal guardian, etc.) THIS AUTHORIZATION WILL EXPIRE YEARLY, UNLESS OTHERWISE REVOKED. Revised: 8/7/13 Created: 4/5/12
7 Dr Shoham New Patient Intake Paperwork Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible. NAME: DOB TODAY S DATE Weight: Height: Pain Description Please use the pain scale described below to rate your pain for the questions below: 0- Pain Free 1- Very minor annoyance, occasional minor twinges 2- Minor annoyance, occasional strong twinges 3- Annoying enough to be distracting 4- Can be ignored if you are really involved in your work/task, but still distracting 5- Cannot be ignored for more than 30 minutes 6- Cannot be ignored for any length of time, but you can still go to work and participate in social activities 7- Makes it difficult to concentrate, interferes with sleep, but you can still function with effort 8- Physical activity is severely limited/ you can read and talk with effort. Nausea and dizziness caused by pain. 9- Unable to speak, crying out or moaning uncontrollably, near delirium 10- Unconscious. Pain makes you pass out What number on the pain scale (0-10) best describes your pain right now? What number on the pain scale (0-10) best describes your worst pain? What number on the pain scale (0-10) best describes your least pain? What number on the pain scale (0-10) best describes your average pain over the last month? Use this diagram to indicate the location and type of you pain. Mark the drawing with the following letters that best describe your symptoms: B = burning D = deep DU = dull E = electric N = numbness SP = sharp SH = shooting S = stabbing B = burning P = pins and needles A = aching T = Throbbing Where is your worst area of pain located? Does this pain radiate? If so, where? : Please list any additional areas of pain: What makes the pain better? What makes the pain worse? MARK ALL OF THE FOLLOWING ACTIVITIES THAT ARE ADVERSELY/NEGATIVELY AFFECTED BY YOUR PAIN: Enjoyment of life Normal Work General Activity Recreational Activities Walking Mood Relationships with People Other:
8 Onset of Symptoms Approximately when did this pain begin? What caused your current pain episode? Is your pain the result of a Motor Vehicle Accident or Personal Injury (legal term used to describe an injury sustained to you by the negligence of another) Yes No How did your current pain episode begin? Gradually Suddenly Since you pain began, how has it changed? Decreased Increased Stayed the same Pain Description Check all of the following that describe your pain: Aching Hot/Burning Stabbing/Sharp Cramping Shock-like Tingling/ Pins and Needles What word best describes the frequency of your pain? Constant Intermittent When is your pain at its worst? Morning During the day Evenings Middle of the Night In the past three months have you developed ANY NEW: Balance Problems Bladder Incontinence Bowel Incontinence Chills Difficulty Walking Fevers Nausea Vomiting Numbness/Tingling Where? Weakness Where? I HAVE NOT RECENTLY DEVELOPED ANY OF THE ABOVE CONDITIOINS. Diagnostic Tests and Imaging Mark all of the following tests you have had that are related to you current pain complaints: MRI of the Date: Facility: X-Ray of the Date: Facility: CT scan of the Date: Facility: EMG/NCV study of the Date: Facility: Other diagnostic testing: I HAVE NOT HAD ANY DIAGNOSTIC TESTS PERFORMED FOR MY CURRENT PAIN COMPLAINTS. Pain Treatment History Mark all of the following pain treatments you have undergone prior to today s visit: Chiropractic Physical Therapy Spine Surgery Epidural Steroid Injection (circle all levels that apply) Cervical/Thoracic/Lumbar Joint Injection Joint(s) Medial Branch Blocks of Facet Injection (circle all levels that apply) Cervical/Thoracic/Lumbar Radiofrequency Ablation (circle all levels that apply) Cervical/Thoracic/Lumbar Spinal Column Stimulator (circle one) Trial Only/ Permanent Implant Vertebroplasty/ Kyphoplasty Level(s) Other: I HAVE NOT HAD ANY PRIOR TREATMENTS FOR MY CURRENT PAIN COMPLAINTS. Current Medications Please indicate which (if any) of the following blood-thinners you are taking: Aggrenox Coumadin/Warfarin Effient Lovenox Plavix Pletal Pradaxa Prasugrel Ticlid Other Please list all medications you are currently taking. Medication Name Dose Frequency
Patient Insurance Information
Improving Lives & Performance Dr. Jeff Eidsvig, D.C., TPI- CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093 972-312- 9310 New Patient Information / Change of Information : New Patient Change
More informationThe 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 informationLast Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
More information21031 Michigan Avenue Dearborn, MI 48124
21031 Michigan Avenue Dearborn, MI 48124 19725 Allen Rd #102 Brownstown, MI 48134 44633 Joy Rd #200 Canton, MI 48187 Phone: 313-277-6700 FAX: 313-277-2483 Date: Dear Patient: An appointment has been scheduled
More informationPatient 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 informationPATIENT /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
More informationName Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
More informationPotomac Valley Chiropractic Personal Injury
Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C. 12105 Darnestown Road, L8 Gaithersburg MD 20878 Please Complete all applicable fields Date: -------------------------------------------------------DEMOGRAPHICS--------------------------------------------------------------
More informationLast Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
More informationCity: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
More informationPraxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
More informationHI *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 informationADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012)
ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012) PATIENT REGISTRATION FORM & FINANCIAL PAYMENT POLICY Patient Info: Please print
More informationNext 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 informationWorker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
More informationDEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION
DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single
More informationWelcome! Please fill out this Patient Registration
Welcome! Please fill out this Patient Registration Personal: (Please Print Clearly, Sign ALL pages and be Complete) Last Name First Name Middle Street City State Zip Home Phone #: ( ) Work / Cell Phone
More informationCENTENNIAL 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 informationWORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
More informationOrthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
More informationOrthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
More informationStonebridge 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 informationLast Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
More informationCHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
More informationBrain & 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 informationHolbrook Chiropractic, PC 233 Union Ave Suite 102, Holbrook, NY 11741 631-981-2222
Holbrook Chiropractic, PC 233 Union Ave Suite 102, Holbrook, NY 11741 631-981-2222 Name: Home Phone: Work Phone: Ext Cell Phone Email Address Home Address City, State, Zip Social Security # Date of Birth
More informationPatient Name: Date of Birth: / / Last First Middle I. Home #: Cell #: Work #: Email Address: Primary Care Physician: Phone: Insurance ID #: Group #:
Patient Name: Date of Birth: / / Race: White Black/African American American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Other Ethnicity: Not of Spanish/Hispanic Descent Spanish/Hispanic
More informationSOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC.
SOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC. 6767 9th Avenue Port Arthur, TX 77642 Ph: (409) 985-9365 Fax (409) 985-6315 I consent to treatment and I authorize payment of medical benefits
More informationPolicy 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 informationName: Date of Birth: Social Security #: Home # Cell # Address: City: State: Zip: Emergency Contact #: Relationship:
California Back and Pain Specialists 14624 Sherman Way, Suite 309, Van Nuys, CA 91405 1172 Swallow Lane, Simi Valley, CA 93065 101 Hodencamp Road, Suite 103, Thousand Oaks, CA 91360 9201 Sunset Blvd, Suite
More informationMVA New Patient Paperwork
Please Complete Entire Form MVA New Patient Paperwork Patient Name: M F Today s Date / / Address: Employer: _ City, State, Zip: Address: Home Phone: ( ) City, State, Zip: Cell Phone: ( ) Work Phone: (
More informationWhen 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 informationINTEGRITY 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 informationDOB: // // Gender: Male Female. Home: Cell: Work:
Core Physical Therapy Clinics, LLC Paper Registration Form Patient Name Date DOB: // // Gender: Male Female Address: City State: Zip Code Home: Cell: Work: Email: Emergency Contact Employer: Name Insurance
More information920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com Thank you for selecting Timberline to be a part of your rehabilitation. Below we have condensed
More informationAdvanced 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 informationOrthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
More information*WELCOME TO OUR OFFICE*
*WELCOME TO OUR OFFICE* WE FIND THAT COMMUNICATION WITH OUR PATIENTS REGARDING OUR BUISNESS OFFICE POLICIES ASSISTS US IN PROVIDING YOU THE BEST SERVICE. THEREFORE WE HAVE PROVIDED A HIGHLIGHT OF SOME
More informationPersonal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
More informationOFFICE 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 informationPAT IENT IN FORMAT ION (P LEASE PR INT) P HYSICIAN & P HARMACY INF O RMAT ION. Address: Phone#: INSURA NCE I NFORMAT IO N.
PAT IENT IN FORMAT ION (P LEASE PR INT) Appointment: I am here to see: Dr. Silberg Dr. Finch Dr. Milia Dr. Patel Dr. Faulkner Patient s last name: First: Middle: Mr. Mrs. Social Security no.: Birth date:
More informationEXCEL PHYSICAL THERAPY, INC.
EXCEL PHYSICAL THERAPY, INC. Medical History Form Name: Date of Birth: Date: Are you employed? YES NO Right Handed Left Handed If NO, last day worked? Do you smoke? YES NO #of packs/day Occupation: Height:
More informationPATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER
More informationLUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B
1 Patient Name In order to properly assess your condition, we must understand how much your BACK/LEG (SCIATIC) PAIN has affected your ability to manage everyday activities. For each item below, please
More informationPersonal Injury Questionnaire
Personal Injury Questionnaire Name Date of Birth Phone Do you want to be contacted via text: Name of cellphone carrier (ie: T-Mobile): Address City State Zip SSN: Weight & Height: Dominant hand: Employer
More informationWelcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
More informationDr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
More informationFunction First Physical Therapy, P.C. Patient Intake Form
Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married
More informationYour 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 informationPATIENT 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 informationIs 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 informationPatient 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 informationPATIENT 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 informationLAST 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 informationCalifornia 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 informationPatient 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 informationDEL MAR PHYSICAL THERAPY Patient Information
PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************
More informationHand & Orthopedic Physical Therapy Associates, P.C.
Patient Name: Hand & Orthopedic Physical Therapy Associates, P.C. Date of Birth: ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) NOTE: If Medicare doesn t pay for items listed below, you may have to pay.
More informationPROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM
Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If
More informationPersonal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
More informationPatient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip:
Welcome to Avenstar Pain Specialists! Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best
More informationPATIENT INFORMATION FORM
737 Pearl Street, Suite 108 Phone: 858.456.2114 Fax: 858.456.2103 www.abilityrehabsd.com PATIENT INFORMATION FORM Please print and complete ALL items. If an item doesn t apply, put N/A Patient Name: Age:
More informationWilliam O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737 Workers Compensation Form First Name MI Last Name Sex Date of Birth Social Security
More informationPreferred 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 informationAll routine calls will be be returned within 24 24 hours, in in the order in in which they were received.
Office Policies We would like to to take the opportunity to to explain the policies of of our office. Please take notice of of include fever, changes with r surgical incision or or increased pain, NO medication
More informationPATIENT 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 informationVirginia 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 informationPatient 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 informationDATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
More informationWelcome 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 informationFaculty 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 informationPATIENT INSURANCE AUTHORIZATION WORKSHEET
PATIENT INSURANCE AUTHORIZATION WORKSHEET We accept all insurances that have in-network and out-of-network benefits. If you do not have insurance benefits for physical therapy, please call us at 858-457-3545
More informationAUBURN MEMORIAL MEDICAL SERVICES, P.C.
AUBURN MEMORIAL MEDICAL SERVICES, P.C. Office Policies We would like to thank you for choosing as your medical provider. We have written this policy to keep you informed of our current office policies.
More information* 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 informationPatient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
More informationThank 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 informationPatient 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 informationIMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
More informationWho to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -
4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)
More informationOffice Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following:
Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following: Please contact our answering service after hours for EMERGENCY
More informationCervical Spine. New Patient Form
Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right
More informationHAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C.
Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C., to provide Care and Treatment to considered necessary
More information7% - 1 /% % 1.14 0 "1,( (1,( 14 - "!#% #"!A(" "4:2 4!(!2"= B"!2 #!B! !("! B!!2"!!"!" -2!
7% -!"!#$$ %&" '()* +,- *+$./- *+$#-*+$ 0 & - 1,-1./-1#-10!1121 1(1.31-2!21021(14 1 /% % 1.14 0 "1,( (1,( 14,35!,%#!61#1,(01141-1-"&-" 1-%11( -" 171.!153-2 -- "-8 -#1#&(19!1&&:1-! &(";!"./
More informationPATIENT INTAKE INFORMATION
PATIENT INTAKE INFORMATION Patient Intake and Worker Compensation / Insurance Information Please have insurance card(s) available for copying Family Physician: Please fill in ALL blanks unless specified
More informationPERSONAL INJURY CASE HISTORY
Name: Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH 43065 (614) 436-9070 (p) ~ (614) 436-8803 (f) PERSONAL INJURY CASE HISTORY 1. Circle the severity (0 = No Pain to 10 = Very Severe Pain)
More informationName: 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 informationWelcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
More informationPhysical Occupational and Speech Therapy Patient Information Sheet
Physical Occupational and Speech Therapy Patient Information Sheet FIRST NAME: MI: LAST NAME: ADDRESS: HOME PHONE: WORK PHONE: MALE FEMALE CELLPHONE: DOB: SS# EMERGENCY CONTACT: PHONE: RELATIONSHIP: PRIMARY
More information1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
More informationHow 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 informationGrapevine 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 informationPatient 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 informationKeweenaw 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 informationCounseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.
Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.org I. Initial Client Information Date: Social Security
More information(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
More informationMILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
More informationAON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?
More informationGrey Physical Therapy and Sports Medicine Center
Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First
More informationBIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )
PATIENT INFORMATION SOCIAL SECURITY # MARRIED SINGLE WIDOW DIVORCED NAME Last First MI HOME ADDRESS BILLING ADDRESS ACCT# DRIVER S LICENSE# BIRTHDATE - - AGE SEX CITY STATE ZIP CITY STATE ZIP PHONE HOME(
More informationPatient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
More information