105 W. Stone Drive, Suite 2B Kingsport, TN Telephone Facsimile
|
|
|
- Edith Hawkins
- 8 years ago
- Views:
Transcription
1 105 W. Stone Drive, Suite 2B Kingsport, TN Telephone Facsimile Scott Fowler, MD, FACOOG Chad Jarjoura, MD, FACOG Renda Knapp, MD, FACOG Christopher Mitchell, MD, FACOG Daphne Schalau, MD, FACOG Christy Stevens, DO, FACOOG Autumn Hoover, NP-C WELCOME Thank you for choosing Seasons Comprehensive Women s Health for your gynecological care. Enclosed is a packet of information you will need to complete and bring with you to your initial visit. Also, please bring your health insurance card and a list of your current medications. We have enclosed a Seasons brochure that provides information about our providers. We welcome you to visit our website at OFFICE HOURS We see patients Monday through Friday, 8:00 a.m. 5:00 p.m., except holidays. Our office staff will be available to answer your phone calls from 8:00 a.m. to 5:00 p.m., Monday through Friday. APPOINTMENTS Please call to schedule your appointments. We make every effort to stay on schedule; however, due to our commitment to providing the most effective patient care, we cannot always predict the length of each office visit. We ask for your understanding if your appointment is delayed. We will keep you as informed as possible regarding delays with our schedule. If you are unable to keep a scheduled appointment, please contact our office as soon as possible. This will enable us to reschedule your appointment to a more convenient time and allow our staff to offer your appointment to someone else. EMERGENCY CARE We do our best to respond to emergencies promptly day or night. If you have a problem that is severe and requires immediate care, please go to the nearest emergency room and the emergency department will contact our provider on call. If the situation is not severe, but you wish to make our office aware of your problem, please call our office at during normal business hours. When our office is closed, all calls are forwarded to our answering service. Our physicians share emergency call coverage at night and on weekends. Our answering service will page our provider on call in the event of an emergency. PRESCRIPTIONS AND REFILLS Requests for prescriptions and refills are handled only during normal office hours. No prescription requests for narcotic medication are processed after office hours or on weekends. Please call our office at least one week before you anticipate needing a prescription refill. Please understand that we are unable to refill prescriptions for you if you have not been evaluated in our office within the last twelve months. PAYMENT Payment for office visits is expected at the time of service. Our practice does participate with numerous insurance plans, and we will be happy to file your insurance claim for you. Please understand we are required by our participation agreements to collect your co-payments and/or deductibles, and these are collected at time of service. You may pay by cash, check, or credit card (Visa, Mastercard or Discover). Please do not hesitate to contact us with any concerns or questions. We look forward to meeting you!
2 Welcome to our office Where did you hear about us? í Yellow Pages (YP) í Newspaper (NP) í Website (WS) í Friend or Family (FF) í Physician Referral (PR) í Other (OT) OFFICE USE ONLY Physician: Approved by: : NEW PATIENT INFORMATION (Complete if different from billing party) Address First Middle Last City State Country Zip Phone # ( ) Birthdate Sex M or F Race Marital Status S M W D Social Security # Employer Address of Employer Work Phone # May we contact you at work? Y N By Y N Address Emergency Contact Emerg. Phone # ( ) Relationship to billing party Guarantor/Responsible Party Address First Middle Last City State Zip Phone # Birthdate Sex M or F Marital Status S M W D Social Security # Driver's License # Place of employment Work Phone # OTHER INFORMATION and address of nearest relative not living with you Address City State Zip Phone # If you are currently under another physician's care, please list: Address City State Zip Whom may we thank for referring you to us? INSURANCE 1. Primary Insurance Company Group # Policy Member # Subscriber Subscriber Birthdate Sex M or F Social Security # Subscriber Employer and Address 2. Secondary/Supplemental Insurance Group # Policy/Member # Subscriber Subscriber Birthdate Sex M or F Social Security # Subscriber Employer and Address Please note whomever brings a child in to be seen is responsible for payment at time of service unless prior arrangements have been made. It is the custodial parent's responsibility to arrange reimbursement from a non-custodial parent. By signing below I hereby give my consent for Holston Medical Group to treat my minor child, under 18 years of age INSURANCE AUTHORIZATION AND ASSIGNMENT: I understand that I am financially responsible for any medical service at time of service. I authorize my insurance carrier to pay to Holston Medical Group any assigned claims filed by them and authorization for release of medical information requested by my insurance company. For Medicare beneficiaries: I request payment of authorized Medigap benefits be made to me or on my behalf to Holston Medical Group and medical information about me to be released to my Medigap insurer. Signature Rev
3 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES MRN: Received: By signing this document, I acknowledge that I have received a copy of the Notice of Privacy Practices, which provides a more complete description of how my protected health information (PHI) may be used or disclosed. I understand that Holston Medical Group reserves the right to change their notice and information practices and that I may view a copy of the current Notice on Holston Medical Group s website, in any of their offices, or by a request in writing. Print Patient Patient of Birth Patient Signature (if applicable) Authorized Representative Signature Relationship to Patient I understand that my protected health information will only be given to those individuals listed below. Those individuals will be required to communicate the last four (4) digits of my Social Security Number, along with my date-of-birth, before any information will be given to them. List the individuals that you want protected health information given to: FOR INTERNAL USE ONLY: Acknowledgement Received: Med Rec # -OR- Reason Acknowledgement Could Not Be Obtained: Employee Signature HMG.001
4 NO SHOW POLICY Welcome to Holston Medical Group. Please take time to review the following information pertaining to our policy for no show appointments. We understand that scheduling conflicts occur from time to time. However, we request at least two hours advance notice if you are unable to keep your scheduled appointment(s). Two or more missed appointments may result in your family being dismissed from Holston Medical Group. Patients that fail to show up for a scheduled appointment may be charged a fee for not providing the office with prior notice of cancellation. Holston Medical Group physicians have developed our No Show policy in an effort to better serve our patients by providing same day appointments to those who are sick and need to be seen. If someone schedules an appointment and does not show for the visit, we have lost an available time that could have been used for a sick patient. We look forward to providing your health care needs. Your understanding and cooperation helps us to provide available appointments for patients who urgently need them. Please sign below as confirmation that you have read, acknowledge and understand our policy regarding no show appointments. Please Print Patient of Birth Account Number Please Sign Authorized Representative Relationship to Patient Witness HMG.550A Rev
5 ADVANCE DIRECTIVES What happens if you become too sick to make your own decisions regarding your medical care? Your family and doctor must decide what treatment to use, when not to treat, and/or when to stop treatment. Your family may not know what you would desire or may not agree on what would be best for you. It is best if they are aware of what you would desire and who you want to make these decisions on your behalf. With the enactment of a federal law, The Patient Self- Determination Act, you have the right to make decisions about your future health care. This includes the right to accept or refuse medical or surgical treatment and to place and direct the types of health care you may receive if you become unable to express your wishes. You can exercise this right by making an Advance Medical Directive. Different providers have, in accordance with the state law, varying practices regarding the implementation of an advance directive. Information regarding such practices must be made available to you, upon request, when selecting or receiving care from the provider. If your physician, as a matter of conscience, is unable to comply with your directives, he/she must take all reasonable steps to arrange to transfer you to another physician. WHAT IS AN ADVANCE DIRECTIVE? An advance directive explains, in writing, your choices about the treatment you want or do not want, or about how health care decisions will be made for you if you are too ill to express your wishes. An advance directive expresses your personal wishes and is based upon your beliefs and values. When you make an advance directive, you will consider issues like dying, living as long as possible, being kept alive on machines, being independent, and the quality of your life. Use of an Advance Medical Directive makes it possible for your wishes to be carried out during a serious illness. If you are an adult and of sound mind, you can make an advance directive. There are two types of formal advance directives. You can complete either a Living Will, a Power of Attorney for Health Care, or both. LIVING WILL A Living will informs your physician that you want to die naturally if you develop an illness or injury that cannot be cured. It tells your physician that, when you are near death or in a vegetative state, he or she should not use life-prolonging measures which postpone, but do not prevent, death. A Living Will allows you to refuse treatments or machines which keep your heart, lungs, or kidneys functioning when they are unable to function on their own. POWER OF ATTORNEY FOR HEALTH CARE The Power of Attorney for Health Care is a form that you may complete to appoint another person (a health care agent ) to make health decisions for you if you are not capable of making them yourself. MAINTAINING YOUR ADVANCE DIRECTIVE You should review and update your advance directive periodically. You have the right to change or discontinue your directive at any time. You should keep your advance directive in a safe place where you and others can easily find it. (Do not keep it in a safety deposit box.) You should make sure your family members and your lawyer, if you have one, know you have made an advance directive and know where it is located. Be sure your physician has a copy of your directive in your medical file. WILL ALL STATES RECOGNIZE MY DIRECTIVES? If you plan to spend time in a state other than your state or residence, from which you obtained your Advance Medical Directives, you may wish to execute advance directives in compliance with that state s laws as well. Specific question should be directed to your physician and/or attorney for guidance. Follow the instructions provided by your state when completing the Advance Directives forms. To obtain additional information, brochures, or forms, you may write to the address below: Tennessee Commission on Aging Nashville, Tennessee I have read and understand the above: : Signature: of Birth: : MRN:
PRESCRIPTIONS AND REFILLS
105 W. Stone Drive, Suite 2 Kingsport, TN 37660 Telephone 423 247 7500 Facsimile 423 247 7556 Scott Fowler, MD, FACOOG Chad Jarjoura, MD, FACOG Renda Knapp, MD, FACOG Christopher Mitchell, MD, FACOG Daphne
OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)
OFFICE POLICIES Thank you for choosing Spencer Dermatology and Skin Surgery Center for your health care needs. We recognize that you have a choice in health care providers and we appreciate the trust that
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
Patient Registration Form
900 Carillon Parkway Suite 404 St. Petersburg, FL 33716 727-572-1333 727-572-1331 fax www.spencerdermatology.com Patient Registration Form Today s : Name: Suffix First Middle Last of Birth: / / Age: Sex:
WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone:
WORKERS COMPENSATION INFORMATION PATIENT INFORMATION Name: Birthdate: Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: Preferred Pharmacy: Tel
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
Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine
Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth Social Security # Male / Female Race Ethnicity (Latino / Non Latino)
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):
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
How To Get A Medical Checkup
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
OFFICE POLICIES, EFFECTIVE October 19, 2009
Thank you for choosing our office for your medical care. We have written these policies to keep you informed of our current office policies. Please refer to our website for policy updates. OFFICE POLICIES,
Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.
Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best
Updated as of 05/15/13-1 -
Updated as of 05/15/13-1 - GENERAL OFFICE POLICIES Thank you for choosing the Quiroz Adult Medicine Clinic, PA (QAMC) as your health care provider. The following general office policies are provided to
Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury:
Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury: PATIENT INFORMATION First Name: Last Name: Date of Birth: Gender: Marital Status: S.S.N.
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
How To Get A Doctor'S Appointment In Holtston
!! 320 Bristol West Blvd., Bldg. 1, Ste. 2C Bristol, TN 37620 Telephone 423.844.1399 Facsimile 423.844.1397 Deana Harmon, DO, FACOOG Samantha Herriott, DO Nicole Long, DO, FACOOG Jeffrey Looney, MD, FACOG
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
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
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 ( )
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
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.
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:
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
Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax)
PATIENT INFORMATION: Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) Last Name: First: MI: Address: City:
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:
PATIENT REGISTRATION FORM
Phone: 831-708-2919 Fax: 831-708-2937 PATIENT REGISTRATION FORM Who may we thank for referring you to us? Name (First, Mid Int. Last) Address City State Zip Code Home Phone w/ area code Email Cell Phone
Anil K. Gupta, M.D. and Gupta ENT Center West www.guptaentcenter.com Pediatric and Adult Otolaryngology
Anil K. Gupta, M.D. and Gupta ENT Center West www.guptaentcenter.com Pediatric and Adult Otolaryngology Welcome to Dr. Gupta s office. We look forward to treating your ENT patient needs. Please review
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)
WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future.
Phone: 717-234-2561 Franklyn J. Myers, III, M.D., F.C.C.P. Alexis B. Aaronson, M.S.N, C.R.N.P. Michele M. Knepper, C.R.N.P. WELCOME TO PCCMA Welcome to our practice. We are specialists in the treatment
Nova Medical & Urgent Care Center, Inc Financial Policy
Welcome and thank you for choosing Nova Medical & Urgent Care Center, Inc (hereafter referred to as Nova ) for your medical care. We are committed to providing you with the highest quality medical care
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
Facts About Dentists and Insurance
Welcome TO THE PRACTICE Patient Information Date Name Birthdate SS# Address City/State Zip Code Driver s License # Name of Employer Check appropriate box Minor Single Married Divorced Widowed Contact Numbers
* 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
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS
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
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
Willow Bend OB/GYN Obstetrics, Gynecology & Infertility
Dear Patient, Welcome to our medical office. We look forward to meeting you soon. In order to provide you with the best possible care, please complete our registration forms prior to your first visit and
Sincerely yours, Rev. 06.10
Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy
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
Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
Saratoga Cardiology Associates, PC 6 Care Lane Saratoga Springs, NY 12866 Phone: (518) 587-7625 Fax: (518) 587-0273
Patient Name: DOB: Soc Sec#: Thank you for choosing Saratoga Cardiology for your cardiac care. We would like to welcome you to our practice. Please complete the attached form for our records and bring
Welcome 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):
Office 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
21031 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
Welcome To Our Physical Therapy Department
Welcome To Our Physical Therapy Department Our entire staff is dedicated to providing our patients with the best possible care and service while keeping the costs to you from increasing at an unreasonable
Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.
BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP
BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP 9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com Welcome! Thank
PATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone #
Boguslaw Gluszak, MD Date: PATIENT INFORMATION Patients Last Name First MI SSN: DOB Age Sex: M F Address City State Zip Code Home Phone # Alt. Phone # Parents/Guardians: N/A Name of Primary Insurance:
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
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
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
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to
Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP
Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP 2501 N. Orange Ave. Suite 589 Orlando, Florida 32804-3520 Phone: 407-303-2080
ADULT CASE HISTORY FORM (AUDIOLOGY)
UGA SPEECH AND HEARING CLINIC The University of Georgia Department of Communication Sciences and Special Education 706.542.4598 (office) 706.542.4574 (fax) ADULT CASE HISTORY FORM (AUDIOLOGY) Please complete
Quiroz Adult Medicine Clinic, P.A. General Office Policies
General Office Policies Thank you for choosing Quiroz Adult Medicine Clinic P.A. (QAMC) as your health care provider. The following general office policies are provided to understand our office protocols
WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.
Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work
1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
Airport Way Dental Care
Airport Way Dental Care A Family Dental Practice Committed to Wellness Welcome to our dental office! Our goal and commitment is to provide our patients with the highest quality dental care through education,
All 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
You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)
Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.
Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record
Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Welcome to my office! Below is some information you may wish to read before your first appointment. Included
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
Worker 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
Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you!
Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you! To simplify the registration process during your first visit we ask that you take a moment
New Perspective Counseling Services Child/Teen Intake Form
Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.
Jodi L. Ceballos, Psy.D. Clinical Psychologist
Hello, my name is Dr. Jodi Ceballos and I am a Licensed who recently relocated to Del Rio. I offer psychological and psycho-educational testing services, as well as individual, couples, and family therapy
If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.
Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to
Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.
Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful
J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C.
J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C. PATIENT REGISTRATION - Please PRINT Clearly Patient Name First Middle Last Date of Birth Age Home Address Apt. No. City State Zip code Occupation Social
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
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
INTEGRATED PHYSICAL THERAPY A Holistic Approach to Physical Therapy
Patient s Name: D.O.B.: Age: Address: City: State: Zip Code: Home Phone #: Cell #: Business #: Social Security Number: E-mail Address: Height: Weight: Referring Physician? Status: Married/Single/Other/Full
Counseling 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
Gay Galleher, Ph.D., A.B.P.P. Board Certified in Clinical Psychology OUTPATIENT SERVICES CONTRACT
Gay Galleher, Ph.D., A.B.P.P. Board Certified in Clinical Psychology Mailing: 10 State Road, Suite 9, Bath, Maine 04530 Office: 579 Berry s Mill Road, West Bath, Maine 04530 207-443-1016 OUTPATIENT SERVICES
Putnam North Family Medical Center An Affiliate of Advance Pain Management of Oklahoma
PATIENT INFORMATION AND PRACTICE POLICIES The Putnam North Family Medical Center's commitment to maintaining a broad knowledge and skill base enables your family to benefit from comprehensive and convenient
Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600
PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company
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,
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
Physical 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
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:
PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:
PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY
Patient Bill of Rights and Responsibilities
Patient Bill of Rights and Responsibilities The patient or the patient s legal representative has the right to be informed of the patient s rights and responsibilities as a patient through effective means
Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record
Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Welcome to my office! Below is some information you may wish to read before your first appointment. Included
PRO SPORTS THERAPY, INC. (P.S.T.)
Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork that you will need to complete and bring with you for your physical therapy evaluation. Please arrive at least 15 minutes
AUBURN 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.
Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address:
Patient Demographics Name: _ of Birth: SS# Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Email: _ Home Address Insurance Information Insurance Provider: Group
IN CASE OF EMERGENCY
THE INFORMATION REQUESTED ON THIS FORM IS USED TO FILE MEDICAL CLAIMS AND FOR OTHER IMPORTANT MEDICAL DOCUMENTATION. PLEASE PRINT LEGIBLY SO THAT WE MAY ACCURATELY REFLECT YOUR PERSONAL INFORMATION IN
OUTPATIENT SERVICES CONTRACT
OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions
Faculty Group Practice Patient Demographic Form
Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred
Community Health Centers of Pinellas, Inc. Women s Health Services Obstetrics & Gynecology
Community Health Centers of Pinellas, Inc. Women s Health Services Obstetrics & Gynecology Amy Gabriel, M.D. Amber Nash, D.O. Erica Schneider, M.D. Angela Stoehr, M.D. Jamie Keene, ARNP Joyce Kepto, ARNP
PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:
To Our New Patient: Our primary concern is providing you with excellent eye care. Your understanding of our policies and your cooperation with our procedures enables us to provide this care. Complete eye
Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889
Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document
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
PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015
Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PATIENT FINANCIAL POLICIES Effective Date: June
YOUR RIGHT TO MAKE HEALTH CARE DECISIONS
This pamphlet informs you about your right to make health care decisions, including the right to accept or refuse medical treatment. It explains the following advance directives and related subjects: YOUR
Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677
Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Welcome! Please take a minute to complete the following information. Your name: Phone Number: Address:
James A. Purvis, Ph.D. Psychotherapy Services Agreement
James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist
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)