Medical History Form
|
|
|
- Carmel Rich
- 8 years ago
- Views:
Transcription
1 MAIN SATELLITE 49 Veronica Avenue Suite West Main Street Suite 203 Somerset, NJ Freehold, NJ P: P: F: F: Rehill Avenue Suite 100 Somerville, NJ P: F: Medical History Form LAST NAME: FIRST: MI: AGE: DATE OF BIRTH: MARITAL STATUS: M S D W Sex: Male Female SS# Home address: (Cannot accept P.O. Box as home address) Street Apt#/Bldg# City State Zip code Mailing address: Street Apt#/Bldg# City State Zip code Home phone: Work phone: Cell phone: address: Can we contact you via ? Yes No Occupation: Employer: Work address: Insurance carrier: Insurance Address: Insurance Phone: ( ) / Effective date: Insured: Insured s DOB: ID: Group: Copay: Reason for consultation Referring physician Primary care physician
2 Past Medical History Check all that apply and list details/diagnoses Myocardial Infarction Diabetes High Blood Pressure Emphysema Irregular Heartbeat High Cholesterol Thyroid Problems Asthma Stroke Coagulation Disorder (you may take Plavix or Coumadin for) Heart Failure Sleep Apnea Cancer Other Other Medical Problems and details: MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs, aspirin or blood thinners: Medication Dose Times per day Medication Dose Times per day SURGICAL HISTORY: Including Defibrillators, Pacemakers or Stents Operation Date Operation Date
3 ALLERGIES or REACTIONS: None Latex Medication Reaction or Side Effect FAMILY HISTORY: Please check all that apply. Medical Condition Mom Dad Sister Brother Daughter Son Other Anesthesia Problem Asthma Bleeding Problems Breast Cancer Colon Cancer Melanoma Thyroid Cancer Parathyroid Cancer Prostate Cancer Diabetes Heart Attack High Blood Pressure Kidney Disease Leukemia Lupus Lymphoma Stroke Vascular Disease
4 SOCIAL HISTORY Tobacco Use Cigarettes Never Current Smoker: packs/day # of years Quit: Date How many years did you smoke? Other Tobacco: Pipe Cigar Snuff Chew Alcohol Use No Yes: # drinks/week PLEASE INDICATE BELOW IF YOU ARE CURRENTLY EXPERIENCING ANY OF THESE SYMPTOMS: General, constitutional Musculoskeletal Does your job require heavy lifting Joint Pain Recent weight change Joint stiffness or swelling Fever Weakness of muscles/joints Fatigue Muscle pain or cramps Back pain Eyes and vision Cold extremities Eye disease or injury Difficulty in walking Wear glasses or contact lenses Blurred or double vision Skin and Breasts Glaucoma Rash or itching Change in skin color Ears, nose, throat Change in hair or nails Hearing loss Varicose veins Ringing in the ears Breast pain Earaches or drainage Breast lump Sinus problems Breast discharge Nose bleeds Mouth sores Neurological Bleeding gums Frequent or recurrent headaches Bad breath or bad taste Light headed or dizzy Sore throat or voice change Convulsions or seizures Swollen glands in neck Numbness or tingling sensations
5 Heart and Cardiovascular Paralysis Heart trouble Stroke Chest pains Head injury Swelling of feet, ankles, hands Psychiatric Respiratory Nervousness Frequent coughing Depression Spitting up blood Sleep problems Shortness of breath Asthma or wheezing Endocrine Gastrointestinal Thyroid disease Loss of appetite Diabetes Change in bowel movements Excessive thirst or urination Nausea or vomiting Heat or cold intolerance Frequent diarrhea Dry skin Painful bowel movements or constipation Change in hat or glove size Genitourinary Hematologic/Lymphatic Frequent urination Slow to heal after cuts Burning or painful urination Easily bruise or bleed Blood in urine Anemia Change in force or strain with urination Phlebitis Incontinence or dribbling Transfusion Kidney stones Swollen glands Sexual difficulty Painful periods Irregular periods Patient Signature: Date:
6 ADVANCED SURGICAL AND BARIATRICS OF NJ Authorization to Obtain or Disclose Health Care Information Patient Name: Date of Birth: Previous Name: My Authorization: You may disclose the following health care information (check all that apply) All health care information in medical record Health care information in medical record Health care information in may medical record relating to the following treatment: Health care information in my medical record for the date (s): Other (e.g., X-days, bills) specify date (s): You may use or disclose health care information re: testing, diagnosis, and treatment for (check all that apply): HIV (AIDS Virus) Sexually transmitted diseases (STD) Psychiatric disorders/mental health Drug and/or alcohol use You may disclose this health care information to: Name: Advanced Surgical and Bariatrics of NJ, PA Address: 49 Veronica Avenue, Suite 202 Somerset, NJ Reason (s) for this authorization (check all that apply): at my request other (specify): on (date): when following even occurs: in 90 days from the date signed (if disclose is to a financial institution or an employer of the patient for purposes other than payment. My Rights I understand I do not have to sign this authorization in order to get health benefits, treatments, payment enrollment). However, I do have to sign an authorization form To take part in research study or To receive healthcare when the purpose is to create health care information for a third party. I may revoke this authorization in writing. If I did, it would not affect any actions already taken by Advanced Surgical and Bariatrics of NJ, PA based upon this authorization I will need to write a letter to Advanced Surgical and Bariatrics of NJ, PA. Once healthcare information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it. Patient or legally authorized Signature Date Time Printed Name if signed on behalf of the patient Relationship
7 Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully OUR PLEDGE REGARDING MEDICAL INFORMATION: The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and service you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we used and share medical information about you. We also describe your rights and cerain duties we have regarding the use and disclosure of medical information OUR LEGAL DUTY Law Requires Us to: Keep you medical information private Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information Follow the terms of the current the notice We Have the Right to: Change our privacy practices and the terms of this notice at any time provided that the changes are permitted by law Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep including information previously created or received before the changes NOTICE OF CHANGE TO PRIVACY PRACTICES: Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon requests USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION: The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use and disclose information for any purpose not listed below, without your specific written authorization. Any specific authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to your doctors, nurses, technicians, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you. FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third party-payer. The information on or accompanying the bill may include your medical information. FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditations, certificates, licenses and credentials we need to serve you. ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment, payment and health care operations, we may use and disclose medical information for the following purposes
8 Facility Directory: Unless you notify us that you object to the following medical information about you will be placed in our facility directories: your name, your location in our facility; your condition described in general terms. Notification: We may use and disclose medical information to notify or help notify; a family member, your personal representative, or another person who is responsible for your care. We will share information about your location, general condition, or death. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is necessary for your healthcare, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-rays or medical information about you. Research in Limited Circumstances: We may use medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy medical information Funeral Director, Coroner, Medical Examiner: To help them carry out their duties, we may share the medical information of a person who has died with a Coroner, medical examiner, funeral director, or an organ procurement organization Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court of administrative order, subpoena, discovery request or other lawful process, under certain circumstances. Under limited circumstances, such as court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. Public Health Activities: as required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration. We may also, when we are authorized by to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition Victims of Abuse, Neglect, or Domestic Violence: We may use and disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped legal custody. Workers Compensation: We may disclose health information when authorize or necessary to comply with laws relating to workers compensation or other similar programs. YOUR INDIVIDUAL RIGHTS: You Have a Right to: 1. Look at or get copies of certain parts of your medical information. You must make your request in writing 2. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency). 3. Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing od that information.
9 Advanced Surgical & Bariatrics of NJ, PA ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY I hereby give permission to Advanced Surgical Bariatrics of NJ to bill my insurance company for professional medical services rendered. I agree to pay all charges due or that become due to Advanced Surgical & Bariatrics of NJ for the care and treatment provided to me by Advanced Surgical Bariatrics of NJ. I understand that insurance benefit verification and authorization is not a guarantee of payment and if the charges are denied, the medical charges will become my responsibility and obligation. I am responsible to pay all copayments, coinsurance and deductible applied to my account after the insurance payment is made and/or the claim is processed. In addition, any charges denied by the insurance company because they do not meet the criteria for medical necessity will be my responsibility. And if I do not or did not provide Advanced Surgical & Bariatrics of NJ with accurate and current information regarding my insurer, I will be personally responsible for the cost of the care rendered. If any claims are billed out-of network under Advanced Surgical Radiology I understand that I will sign the back of the check received by me and send it with a copy of EOB to advanced Surgical Radiology. I am only responsible for what is paid. If nothing is paid, I am only responsible to send a copy of the EOB showing no payment was made. I will NOT be billed for deductibles, co insurance, etc for the out-of network billing.if I do not follow this procedure for out-of network billing, I understand I will be responsible for the full amount billed to the insurance company. I agree that all bills are to be paid when presented or in advance of treatment, itself pay. And if I fail to pay my bill, I realize that my account will be forwarded to collection agency and attorney and court fees will be added to my balance due. Date: Name: Signature: (Optional) I hereby give Advanced Surgical & Bariatrics of NJ permission to charge my credit/debit card for copayments, coinsurance, and deductible dues and all non-covered charges. CD#: Expiration: Type: Signature:
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
Plano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
Pulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION
PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
Women s Continence and Pelvic Health Center
Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
Emory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions
PRIVACY POLICY (IN ACCORDANCE WITH HIPAA)
PRIVACY POLICY (IN ACCORDANCE WITH HIPAA) The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. This
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
NEUROLOGY SPECIALISTS of Monmouth County, NJ 107 Monmouth Rd #110 West Long Branch, NJ 07764 732-935-1850
107 Monmouth Rd #110 West Long Branch, NJ 07764 732-935-1850 We are grateful that you have chosen our practice for your medical needs. We look forward to seeing you at your initial appointment. It is extremely
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.
155 McDonald Drive SW Shirley E. Charette, MS, PA-C
LAKELAND FAMILY MEDICINE Dennis J. Charette, M.D. 155 McDonald Drive SW Shirley E. Charette, MS, PA-C Carri A. Meiler, MS, PA-C Phone: 330-308-8999 Fax: 330-308-8016 www.lakelandfamilymedicine.com PATIENT
Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:
Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
Princeton and Rutgers Neurology, P.A. A Center Of Excellence
DEMOGRAPHICS Patient s Last Name: First Name: Address: City: State: Zip Code: Tel # (Cell): Tel # (Home): Tel # (Work) #: Preferred Method Of Contact: [] Cell Phone [] Home Phone [] Work Phone SS #: /
Motivation to achieve these goals: 1 2 3 4 5 6 7 8 9 10
New Patient Application and Case History (H) Name Age Sex: M F DOB Today's Date Address City State Zip Home Phone Work Phone Cell Phone e-mail: May we leave a voice mail? Y N Height Weight: How Did You
1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
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)
IF THIS IS RELATED TO A WORKMAN S COMPENSATION CLAIM OR AN AUTOMOBILE ACCIDENT, PLEASE FILL OUT ADDITIONAL SHEET IN THE BACK OF THIS PACKET (PIP FORM)
PATIENT INFORMATION Last Name: First: MI: of Birth: Social Security #: - - Address: City State Zip Home#: ( ) - Cell#: ( ) - Employer: Employer#: ( ) - Occupation: Retired Unemployed Student Self-Employed
PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
Personal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer
Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.
: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:
RALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Date Patient s Name Last First Initial Street Address City State Zip Code Phone No. Date of Birth Age Sex Married/Single Family Doctor Patient s Social Security No. - - Referring
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)
REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please
How to Remove a Social History Smoke?
AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:
PATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
Patient Demographics Sheet
Patient Demographics Sheet PLEASE PROVIDE YOUR PHARMACY INFORMATION BELOW: PREFERRED PHARMACY: PHARMACY LOCATION: PHARMACY PHONE NUMBER: FOR OFFICE USE ONLY Dr. Goldblatt Dr. Brown Last Name: First Name:
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER:
Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
PATIENT REGISTRATION. First Name: Middle Initial: Last Name: Home Phone: Work Phone:
PATIENT REGISTRATION First Name: Middle Initial: Last Name: Address City, State, Zip: Home Phone: Work Phone: Cell Phone: Birth Date: Age: Sex: Male Female Soc. Sec. #: Occupation: Employer: Marital Status:
Welcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear
Welcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear If you are a new patient to our practice and would like to complete new patient forms before you arrive, please print
WORKERS COMPENSATION INFORMATION
WORKERS COMPENSATION INFORMATION PATIENT REGISTRATION INFORMATION 15215 Shady Grove Rd. # 100 Patient Name: Last First MI Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Primary Doctor:
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
Financial/Office Policy Brandon Family Medical Care, P.A. 414 West Robertson Street Brandon, Florida 33511 (813) 684-5255
Brandon B Family MEDICAL CARE Financial/Office Policy The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make
CAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
PATIENT SELF-ASSESSMENT FORM
PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:
PATIENT INFORMATION FORM. Name: Address: City: State: Zip: Social Security Number: Telephone Numbers Home: Age: Sex: M / F Work: Email: Cell:
PATIENT INFORMATION FORM Name: Address: City: State: Zip: Social Security Number: Telephone Numbers DOB: Home: Age: Sex: M / F Work: Email: Cell: Marital Status: Single Married Spouse s Name: Widowed Divorced
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)
OFFICE POLICY. I, have read and understand the Financial Policy of Brandon Family Medical Care and agree to meet all financial obligations.
OFFICE POLIC The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make your visits as convenient as possible.
Medical Insurance and Vision Plans
Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit
Creekside Physical Therapy and Rehabilitation
Creekside Physical Therapy and Rehabilitation PATIENT INFORMATION Patient s Name: Social Security #: Age: Sex: M/ F Date of Birth: Email: Home Address: City: State: Zip: Telephone (Hm): Work: Mobile: Employer:
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
Interventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
Agnes Ju Chang, M.D., F.A.A.D.
Agnes Ju Chang, M.D., F.A.A.D. Dear Valued Patient: Thank you for choosing Integrated Dermatology of K Street, the office of board certified dermatologists, Dr. Agnes Ju Chang, Dr. David A. Lee, Allison
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION Last Name First Name MI Mailing Address City Zip code Home Phone
Cutting Edge Eye Care
Cutting Edge Eye Care The Optos Daytona provides an unequaled 200 degree view of your retina in a single image. This view gives our doctors the opportunity to identify and follow peripheral retinal pathology
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834 Dear New Patient: Welcome to Associates in Pediatric and Adult Urology, PA, a
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
A photocopy of this document shall be considered as effective and valid as the original.
p In order for us to obtain a complete medical history, it is important for you to fill out this form in its entirety. Every item needs to be filled out. This information will be entered into our Electronic
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
CONSENT FOR TREATMENT
PATIENT INFORMATION PERSON FINANCIALLY RESPONSIBLE LAST NAME FIRST M.I. NAME RELATIONSHIP TO PATIENT PREFERS TO BE CALLED BY MALE FEMALE BIRTH DATE SOCIAL SECURITY NO. BIRTH DATE SOCIAL SECURITY NO. ADDRESS
AON 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?
PLEASE PRINT LEGIBLY
Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
PRE-EXAM QUESTIONNAIRE
Matthew T. Stanley, O.D. Darcy D. Stanley, O.D. Doctors of Optometry Patient #: PRE-EXAM QUESTIONNAIRE Name: Sex: M F Today s Date: / / Name you prefer to be called: Home Phone: Street Address: Daytime
PEDIATRIC MEDICAL HISTORY FORM
Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS
PLEASE PRINT PATIENT LAST NAME: FIRST NAME DATE OF BIRTH: / / AGE: ADDRESS: APT CITY STATE ZIP HOME PHONE # CELL PHONE # WORK PHONE # SEX M F MARITAL STATUS DRIVER S LICENSE # SOCIAL SECURITY # - - EMPLOYER
Relation Address City State Zip Code
To enable us to provide you with the best possible care, please complete the following: Date: Name Social Security # First Full Middle Last Address City Zip Code_ Telephone (home) (work) Date of Birth
Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #
Patient Information Patient Name Date of Birth If Patient is child, Parent s Name Street Address Male or Female City State Zip Cell# Home# Work# Name of Employer Email Address SS# of Patient Driver s License
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
TALLAHASSEE EYE CENTER
TALLAHASSEE EYE CENTER PATIENT INFORMATION Date: Name: Gender: M / F First MI Last Date of Birth: / / Address: City: State: ZIP: Phone Numbers: Home: Cellular: Work: E-Mail: SS#: - - What is the best way
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
STERLING PRIMARY CARE 343 Franklin Road, Suite 203 Brentwood, TN 37027 Phone (615) 577-6520 Fax (615) 577-6521 PATIENT REGISTRATION FORM
STERLING PRIMARY CARE 343 Franklin Road, Suite 203 Brentwood, TN 37027 Phone (615) 577-6520 Fax (615) 577-6521 PATIENT REGISTRATION FORM PATIENT INFORMATION (Please Print) Dr. Mr. Mrs. Ms. Jr. Sr. Other
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
Luna Spine and Orthopaedic Surgery Mario E. Luna, MD
PATIENT INFORMATION NAME (Last, First, Middle Initial) PRIMARY ADDRESS PATIENT REGISTRATION FORM EMERGENCY CONTACT NAME (Relationship to Patient) CITY, STATE, ZIP CITY, STATE, ZIP PHONE ( ) HOME ( ) CELL
PATIENT DEMOGRAPHICS:
PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?
New Patient Registration Form
New Patient Registration Form PLEASE PRINT How did you learn about our practice? DATE Physician Relative Friend Website Phone book Newspaper Other Patient s Full Name Age Home Address City State Zip Home