Welcome to our office
|
|
|
- Thomasina Fox
- 5 years ago
- Views:
Transcription
1 Welcome to our office Where did you hear about us? Yellow Pages (YP) Newspaper (NP) Website (WS) Friend or Family (FF) Physician Referral (PR) Other (OT) OFFICE USE ONLY Physician: Approved by: : NEW PATIENT INFORMATION (Complete if different from billing party) Name 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 Name Emerg. Phone # ( ) Relationship to billing party Guarantor/Responsible Party Name 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 Name 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: Name Address City State Zip Whom may we thank for referring you to us? INSURANCE 1. Primary Insurance Company Name Group # Policy Member # Subscriber Name Subscriber Birthdate Sex M or F Social Security # Subscriber Employer and Address 2. Secondary/Supplemental Insurance Name Group # Policy/Member # Subscriber Name 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
2 MRN: DATE RECEIVED: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing this document, I acknowledge that I have reviewed and/or 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. I also understand that Holston Medical Group participates in the OnePartner Health Information Exchange (OnePartner HIE) and may make my medical information available electronically, or may electronically transmit my medical information to a third party, in order to fulfill provider obligations to release my medical information in the future. Print Patient Name Patient of Birth Patient Signature (if applicable) Authorized Representative Signature Relationship to Patient I understand that my protected health information will only be verbally communicated to those individuals listed below. Those individuals will be required to provide the last four (4) digits of my Social Security Number, along with my date-of-birth, before any information will be discussed with them. List the individuals that you want protected health information given to: FOR INTERNAL USE ONLY: Reason Acknowledgement Could Not Be Obtained: Employee Signature
3 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 Name of Birth Account Number Please Sign Authorized Representative Relationship to Patient Witness HMG.550 Rev
4 Sapling Grove Pediatrics and Internal Medicine Name D.O.B. Address City State Zip Phone (Home) Phone (Work) Occupation Years at your job Marital Status Number of Children List your current exercise regimen Do you use any of the following (Please check and list approximate amount of usage): TOBACCO Currently use Amount used per day Use cigarettes Use Chewing Tobacco, Skoal, Snuff, Used in past but do not use now Number of years since used ALCOHOL Number of drinks per day DRUG ALLERGIES (Please list medication and the reaction) Please list approximate date of last vaccine for the following: Pneumonia Diphtheria Hepatitis Pertussis Measles Polio Mumps Tetanus Rubella Flu PERSONAL PAST MEDICAL AND SURGICAL HISTORY: (Please list approximate date and illness or surgery) LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING: (Please include over the counter medications and inhalers) HMG.SGPED.220 page 1
5 HEALTH MAINTENANCE INFORMATION (Please list date for the following) Female PAP Mammogram Male PSA Everyone Chest X-Ray EKG Colonoscopy or Flex. Sig. FAMILY MEDICAL HISTORY (Please list any blood relative who has suffered from any of the following - Please indicate which relative) Tuberculosis Stroke Migraine Headaches Mental Illness (Manic Depressive, Schizophrenia, Depression, etc.) Epilepsy Diabetes Cancer (List who and what type) Allergies Arthritis Gout Kidney Disease Glaucoma Osteoporosis Hypertension Heart Attack HMG.SGPED.220 page 2
6 MEDICAL HISTORY - Mark C for current or place and indicate the age when you had any of the following illness or disease: Main Problems (1) (2) Decreased Hearing Ringing in Ear Ear Infections Dizzy Spells Failing Vision Double or Blurred Vision Eye Pain Eye Infections - Frequent Nose Bleeds - Recurrent Sinus Trouble Sore Throat - Frequent Hay Fever / Allergies Hoarseness - Prolonged Pneumonia / Pleurisy Bronchitis / Chronic Cough Asthma / Wheezing Shortness of Breath on exertion lying flat Chest Pain High Blood Pressure Heart Murmur Palpitations Irregular Pulse Swollen Ankles Fainting Spells Chronic Fatigue Weight Loss - Recent Anem ia Bruise Easily Cancer Diabetes Convulsions / Seizures Tremors / Hands Shaking Numbness / Tingling Sensations Headaches - Frequent Back Pain - Frequent Gout Rashes Hives Psoriasis Eczema Sleeping Difficulty Nervousness Moodiness - Excessive Mental Illness Contact with Blood or Body Fluids Job Volunteer Leg Pain when Walking Varicose Veins / Phlebitis Loss of Appetite - Recent Difficulty Swallowing Indigestion or Heartburn Permanent Nausea / Vomiting Peptic Ulcer Abdominal Pain - Chronic Change in Bowel Habits - Recent Diarrhea Constipation Diverticulosis Bloody or Tarry Stools Hemorrhoids Gallbladder Trouble Jaundice / Hepatitis Hernia Urine Infections - Frequent Painful Urination Blood in Urine Overnight Urination - more than 2 Control in Urination Decrease in force of Urination Kidney Stones Venereal Disease Urethral Discharge Chicken Pox Pox Measles German Measles Rheumatic Fever Mumps Tuberculosis Thyroid Disease Stroke Muscle Weakness Arthritis / Rheumatism Bone Fracture / Joint Injury Foot Pain Cold Numb Feet Memory Loss Depression Phobias FEMALES: Onset age of Menses Regular Irregular Flow: Heavy Moderate Light Pain / Cramps with Menses Flow Days of Flow Length of Cycle of 1 st Day of Last Period Pain / Bleeding after Sex Number of Pregnancies Number of Live Births Number of Miscarriages Birth Control Method BC Pill Name Flushing / Menopause HMG.SGPED.220 page 3
7 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 those 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 plan 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 Directive. Different providers have, in accordance with 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 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 vegetable state, he or she should not use life prolonging, measures which postpone, but do not prevent, death. POWER OR ATTORNEY FOR HEALTH CARE The Power or Attorney for health care is a form that you can complete to appoint another person (a health care agent ) to make health care 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 safe 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 advance directive in your medical file. Most states have specific rules as to what will be recognized as a valid advance directive. Below is an address for further information. DO ALL STATES RECOGNIZE MY DIRECTIVES? If you plan to spend time in a state other than your state of residence, from which you obtained your Advance Medical Directive, you may wish to execute advance directives in compliance with that state s laws as well. Specific questions should be directed to your physician and or attorney for guidance. Follow the instructions provided by your state when completing the Advance Directive forms. To obtain additional information, brochures, or forms you may write to the address below: Tennessee Commission on Aging Nashville, TN Virginia Department for the Aging 1610 Forest Avenue, Suite 100, Richmond, VA I have read and understand the above: Name: Signature: of Birth: : MRN:
DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group
DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group Date: NAME: AGE: DOB: Why are you here to see the doctor today? REFERRED BY: INSURANCE HEALTH GRADES INTERNET FRIENDS/RELATIVES PCP OTHER: Medications
Welcome to our office
Welcome to our office Where did you hear about us? Yellow Pages (YP) Newspaper (NP) Website (WS) Friend or Family (FF) Physician Referral (PR) Other (OT) OFFICE USE ONLY Physician: Approved by: Date: NEW
New Patient Registration Form NJR_NP_F100
New Patient Registration Form NJR_NP_F100 Patient Last Name First Name Middle Name Maiden Name Address (Street or Box) City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-Mail Patient
WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you
PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:
Allergies Drug Food Environmental. Previous Surgeries & Hospitalizations (Please list date, reason, and hospital)
Allergies Drug Food Environmental Previous Surgeries & Hospitalizations (Please list date, reason, and hospital) Habits Do you ever use the following? If yes, how often? Tobacco Alcohol Recreational Drugs
College of Sequoias Physical Therapist Assistant Program Student Health Release Form
Part A: College of Sequoias Physical Therapist Assistant Program Student Health Release Form To be completed by the Student Name: Telephone: Cell Number: Address: City: ZIP Code: Birth Date: Family Health
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
Age: Birthdate: Date of Last Physical exam:
Name: : Age: Birthdate: of Last Physical exam: SYMPTOMS: Check symptoms you currently have OR have had within the past YEAR. General Fever Chills Weight loss Weight Gain Headache Depression Vertigo Ringing
May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female
1 Health Information and Health History Patient Name: Gender: Male Female Marital Status: (Circle one) M S D W Other: Date of Birth / / Spouse Name: How many children: Patient Social Security Number: -
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
ADULT PATIENT INFORMATION. Patient Name: Last Name First Name Address: City: State: Zip Code: Phone #: Cell Phone #: Social Security:
716 S. Goldenrod Road n 3315 Orange Blossom Trail Fax (407) 658-2536 Fax (407) 343-1907 ADULT PATIENT INFORMATION Patient Name: Last Name First Name MI Address: City: State: Zip Code: Phone #: Cell Phone
Entrance Case History (Please write or print clearly)
Stony Brook Medical Park 2500 Nesconset Highway Suite 4-A Stony Brook, NY 11790 (631) 675-9000 Fax (631) 675-9002 www.naturalapproach.us Entrance Case History (Please write or print clearly) Today s Date
Patient Communication Request
Patient Communication Request Name: Date of Birth: Address: ZIP: Home Phone: Work Phone: Cell Phone: E-mail address: It is the policy of Capstone Family Practice to contact patients for any lab results.
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
Naturopathic Wellness Center
Naturopathic Wellness Center Ashley G. Lewin, N.D. Erica Waters, ND Mychael Seubert, ND Pediatric Intake Birth to 3 years Name Sex Date of Birth / / Age Parent(s)/Guardian(s) Address City/State/Zip Telephone
Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred
Pediatric New Patient Form
Pediatric New Patient Form Internal Medicine & Pediatrics Patient Information Today's Date: Legal Name: Gender: M / F Date of Birth: Age: Race : Ethnicity: E-mail Address: Other: Home Address: Primary
Last Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone
Last Name First Middle Mailing Address City State Zip Phone Date of Birth Age Soc. Sec# Cell Employer Work Phone Email Address Emergency contact Phone # Relation: Name of Primary Insurance Policy # -----
Name DOB / / SS# / / Street Address City/State/Zip. Home ( ) - Cell( ) - Work( ) - Emergency Contact Day Phone( ) -
Wellesley Women s Care, P.C. PPG Thank you for taking the time to complete this form. We ask that you complete this entire form once a year or when you have any NEW information. PATIENT INFORMATION (Please
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Patient Name: Date of Birth: SSN: Cell Number: Cell Phone Provider: Home Number: Work Number: Home Address: City/State: Zip: Employer: Occupation: E-Mail: Relationship Status: S M W
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell
Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address
Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR 97031 541-387-6125 fax 541-387-6315 Physician Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and
TRINITY DENTAL CLINIC Medical History Form Date:
Page 1of 4 TRINITY DENTAL CLINIC Medical History Form Date: NAME DATE OF BIRTH ADDRESS CITY STATE ZIP PHONE NUMBERS PHYSICIAN DO WE HAVE PERMISSION TO LEAVE A MESSAGE AT THE PHONE NUMBERS LISTED ABOVE?
Dear Patient, Sincerely, Gastroenterology Associates of North Jersey
GASTROENTEROLOGY ASSOCIATES OF NORTH JERSEY, P.A. Doctors Park 369 West Blackwell Street, Dover, NJ 07801 16 Pocono Road, Suite 210, Denville, NJ 07834 Tel (973) 361-7660 Fax (973) 361-0455 Tel (973) 627-7600
COLON & RECTAL SURGERY, INC.
COLON & RECTAL SURGERY, INC. Please complete attached paperwork and bring to your appointment with your insurance card, co-pay and photo ID. If a referral is required, please be sure to contact your insurance
Virginia Heartburn & Hernia Institute
Virginia Heartburn & Hernia Institute PATIENT INFORMATION FORM (Please make sure to print clearly and sign at the bottom of this page) Patient s Last Name: First: Middle Initial: Marital Status: Married
2200 Northern Boulevard, Suite 133 East Hills, NY Fax (516) Transitional Care
2200 Northern Boulevard, Suite 133 East Hills, NY 11548 855-670-6077 Fax (516) 918-9039 Transitional Care Dear New Patient: We welcome you to our practice as a transitional patient. We will be managing
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP
New Patient Intake Form Patient Information Thank you for choosing our practice for your chiropractic needs. Please fill out this form as completely as possible. If you have any questions or concerns,
PATIENT REGISTRATION FORM
Natalie A. Nealeigh, PA-C PATIENT REGISTRATION FORM PATIENT INFORMATION (PLEASE PRINT) Last Name: First Name: MI: Street Address: City: State: Zip: Home #: Cell #: Work #: DOB: Age: Sex (M/F): Marital
Bellevue Neurology PATIENT DEMOGRAPHIC FORM
PATIENT DEMOGRAPHIC FORM Name Today s date / / Last First M.I. Mailing Address Age Number, Street, Apartment Number City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Date of Birth / / SS # Marital
Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet
Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, 63119 314.484.0690 Patient Data Sheet Date Name: Address: City: State: Zip: Social Security Number: - - Email: Home Phone: ( ) Cell Ph.: ( ) Work Ph.:
PATIENT INFORMATION SHEET:
PATIENT INFORMATION SHEET: LAST NAME: FIRST NAME/MI: ADDRESS: CITY: STATE: ZIP CODE: SOCIAL SECURITY #: HOME: CELL: WORK: SEX: M F BIRTHDATE: MARITAL STATUS: SINGLE MARRIED WIDOWED OTHER EMPLOYER NAME:
Workers' Compensation Demographic Form. Patient Information
Workers Comp Patient Demographic Workers' Compensation Demographic Form Please Print Clearly Patient Information Date of Visit Account Number Workers' Compensation Coordinator Patient Name (Last, First,
(Please Print) PATIENT INFORMATION. Sex: Male Female Home phone no: ( ) City: State: Zip: Cell phone no: ( ) Occupation: Employer: Work phone no: ( )
(Please Print) Today s date: Primary Care Physician: PATIENT INFORMATION First name: Middle: Last: Former name: Marital Status: Single Married Divorced Widowed Street address: Birthdate: SSN: Email Address:
Hello and Welcome! I truly look forward to working with you and your child on the journey towards optimal health. Warmly, Amanda H.
Hello and Welcome! Attached you will find pediatric intake forms. Before your child s scheduled appointment, please fill out the forms as thoroughly as possible. I know your time is valuable and by bringing
Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
PATIENT REGISTRATION
PATIENT REGISTRATION Date: Patient Name Last First Middle Initial (Nickname) Home Address Street Apt# City State Zip ( ) Male ( ) Female Body part being evaluated Marital Status: ( ) Single ( ) Married
Thank you for choosing Southern WV Endocrinology. Enclosed you will find your new patient
Welcome, Thank you for choosing Southern WV Endocrinology. Enclosed you will find your new patient paper work that must be completed and mailed back to us as soon as possible. Please bring your medication
Please allow us hours to refill the medication; approval from your medical provider is required on all refills.
Thank you for choosing Rex Primary Care of Holly Springs for your primary care needs. To keep our patients better informed we have created a list of our office policies to make your visit and continuation
Patient Demographic Sheet
Patient Demographic Form Please PRINT Patient Demographic Sheet Last name First Name Middle Initial Date of Birth Social Security Number Gender Male Female Marital Status Married Single Divorced Life Partner
Your annual preventive visit, or complete physical exam, is scheduled with. Dr. on at AM/PM.
Dear: Your annual preventive visit, or complete physical exam, is scheduled with Dr. on at AM/PM. Please bring the following with you on the date of your appointment: A list of your current medication(s),
Patients Name. Insurance policy holders name and Social security number. Address. Home Phone number. Work Phone Number
Patient Registration Form Print out this form and also the Health History Form. Bring both fully completed forms and your insurance card with you and give them to our staff as you check in for your appointment.
Patient Name: Last First Middle
Wilmington Ear Nose & Throat Associates, PA Patient Information Form Patient Name: Last First Middle Mailing Address: Street Address (if different from above): City: State: Zip Code: Social Security #:
New Patient Paperwork
Your Vision Is Our Focus New Patient Paperwork Dear Patient, Please fill out all of the following pages, and bring them with you to your scheduled appointment time. If you have questions regarding your
MARATHON HEALTH CENTER a benefit of CHG Health and Wellness
Health & Wellness MARATHON HEALTH CENTER a benefit of CHG Health and Wellness WE ARE A DIFFERENT KIND OF HEALTHCARE COMPANY. OUR MISSION IS TO INSPIRE PEOPLE TO LEAD HEALTHIER LIVES. CHG Healthcare Services
2017 Medi-Slim Weight Loss Patient Information Form
Medi-Slim Weight Loss Patient Information Form Patient Name (Last) (First) (MI) Name you prefer to be called: Patient Address: City:_ State Zip Phone number you would prefer us to use: May we email you?
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT You are scheduled to have an appointment at the UPMC Liver Cancer Center which is located in the UPMC Montefiore
SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely)
SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely) Name: Former/ Maiden Name: Date of Birth: Age: Today s Date: *Language: Race: Ethnicity: *Do
LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W
PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
PATIENT INFORMATION & CONDITION FORM
PATIENT INFORMATION & CONDITION FORM Patient Name: Today's Date: / / Social Security Number Birth Date: / / Age: Gender: F M Email Height : Weight: Specify Right or Left Handed Have you ever been in our
Patient Information: Last Name First Name MI. Address Apt/Room # City Zip. Community name (if not at home) Martial Status: S M W D
HouseCalls-MD 2998 W. Montague Ave. Suite 117 N. Charleston, SC 29418 Info@housecalls-md.com Office 843-501-2031 www.housecalls-md.com Fax 888-453-0810 Patient Information: Last Name First Name MI Gender
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address
Dear New Patient. Tarrant County Medical Institute values its patients and is committed to providing them with the highest of quality care.
Dear New Patient Tarrant County Medical Institute values its patients and is committed to providing them with the highest of quality care. You have made us aware that you will be the responsible party
Burton M. Sundin, M.D. / Reps B. Sundin, M.D. Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: address:
Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: Email address: Patient Status: 1-Married 2 Single 3-Separated 4-Divorced 5-Widowed 6-Other Birthdate: Sex: Social Security#:
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty Consent for Purposes of Treatment, Payment and Health Care Operations I consent to the use or disclosure of my protected health information by Florida
Family Medicine Division. Nyree Bryant DO George R. Davis DO
Family Medicine Division Nyree Bryant DO George R. Davis DO 11/12/17 Dear New Patient, Welcome to Florida Medical Clinic! We are happy that you have made our office your choice for your medical care needs.
Rafael Villarosa, M.D Terracina Blvd. #207 Redlands, CA (909) Fax (909) Welcome!
Welcome! Rafael Villarosa, M.D. www.drvillarosa.com 255 Terracina Blvd. #207 Redlands, CA 92373 (909) 793-2226 Fax (909) 793-3336 Please find enclosed the new patient forms to complete and bring to your
Rafael Villarosa, M.D Terracina Blvd. #207 Redlands, CA (909) Fax (909) Welcome!
Welcome! Rafael Villarosa, M.D. www.drvillarosa.com 255 Terracina Blvd. #207 Redlands, CA 92373 (909) 793-2226 Fax (909) 793-3336 Please find enclosed the new patient forms to complete and bring to your
PATIENT INFORMATION. Address: Sex: City: State: address: Cell Phone: Home Phone: Work Phone: address: Cell Phone:
PATIENT INFORMATION Name: _ DOB: _ Age: Address: _Sex: City: _ State: _ Zip: _ Email address: Cell Phone: _ Home Phone: Work Phone: _ Responsible Party (if different from above) Name: DOB: Address: E-mail:
MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email
Ambassador Program Application Packet
Ambassador Program Application Packet Thank you for your interest in becoming an Ambassador at Centinela Hospital Medical Center. Please complete the attached forms and then contact the Centinela Hospital
Sonas IMC, Inc. 555 S Camino Del Rio B2 Durango, CO Tel: Fax: New Patient Information Sheet (Please Print Clearly)
New Patient Information Sheet (Please Print Clearly) PATIENT INFORMATION: Date: Name: ( ) Mailing Address: City: State: Zip: Date of Birth: Age: SS#: Sex: F M Martial Status: S M D W Other: Spouse Name:
M or F Patient s Date of Birth Patient s Social Security Number Sex. Secondary Address: (if have, Northern) Street City State Zip Code
PATIENT REGISTRATION PLEASE PRINT Today's Date: Referred by: Patient s Name: Last First M.I. M or F Patient s Date of Birth Patient s Social Security Number Sex Primary Address: Street Apt/Unit # City
BETHESDA DENTAL GROUP
PLEASE COMPLETE ALLINFORMATION THAT APPLIES TO YOU - THANK YOU PATIENT LAST NAME: FIRST: INITIAL How did you hear about us? Whom may we thank for your referral? Date of Birth: Single: Married: Divorced:
Neck & Spine Patient Demographic
Neck & Spine Patient Demographic o New Patient o Return Patient o Update Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg.
Welcome To Health First Chiropractic
Welcome To Health First Chiropractic Dear Patient: Please complete this questionnaire. Your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will
Student s Name: Evaluator s Name: ABHES/CAAHEP Standard 10.b4.2 2.b.2 3.a.2 3.b.2 4.a.2 8.cc.2 8.dd.2 9.a.2 9.a.2 9.d.2 9.p.1
Page 1 of 6 Collecting Measurements, Visual Acuity, and Recording Patient History Competency Rev 09-11 Student s Name: Date: Evaluator s Name: ABHES/CAAHEP Standard 10.b4.2 2.b.2 3.a.2 3.b.2 4.a.2 8.cc.2
WELCOME TO OUR PRACTICE
LVPG INTERNAL MEDICINE Phone 484-661-4650 Fax 610-402-1153 3080 Hamilton Boulevard, Suite 350 Allentown, PA 18103 Office Hours: Monday: 8:00 a.m. 9:00 p.m. Tuesday Friday: 8:00am 5:00pm WELCOME TO OUR
Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with?
Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with? 1. 2. 3. IMPORTANT PLEASE BRING A COMPUTER DISK WITH ANY BRAIN
NEW PATIENT INFORMATION Primary Care Physician
Last Name NEW PATIENT INFORMATION Primary Care Physician Date: First Name MI Referring Provider Previous Name Date of Birth (mm/dd/yyyy) Address City Gender Male Female Marital Status Single Divorced Married
Fulcrum Orthopaedics Patient Registration Packet
Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 8 Consent for Use and Disclosure of Information 9 Authorization for Use and Disclosure of Protected Health Information 10 Notice
New Patient Intake Questionnaire
New Patient Intake Questionnaire NAME: DATE: / / BIRTHDATE: / / REFERRED BY: AGE: REASON FOR VISIT: LOCATION OF PAIN: BACK HIP BUTTOCK LEG FOOT RIGHT LEFT NECK ARM SHOULDER HAND RIGHT LEFT OTHER (DESCRIBE)
Welcome to the Southeastern Urology Associates meridianemr Patient Portal
New Patients: Please register for our Portal following the instructions below and send us a Message though the New Message Message for Office Section to let us know you received this packet and are confirming
Thompson Medical Group New Patient Registration Form
Thompson Medical Group New Patient Registration Form PLEASE PRINT Last Name: First Name: MI: Sex: Male / Female Date of Birth: Age: Race (i.e. Caucasian/Hispanic/Asian): Ethnicity (i.e. American/Mexican/German):
DEMOGHRAPHICS INSURANCE INFORMATION
DEMOGHRAPHICS Name: Date of Birth: / / AGE: Street Address: City: State: Zip: Home Phone #: ( ) Cellular Phone :( ) Social Security Number: E-mail: Marital Status: Single Married Divorced Widowed Employer:
PATIENT HEALTH QUESTIONNAIRE
PATIENT HEALTH QUESTIONNAIRE Last Name: First Name: MI: Date of Birth: SS#: Address: City: St: Zip: Cell#: Home #: Work#: Which number is the best way to reach you? Cell Home Work Email Address: Preferred
PHONE: (813) FAX:
Welcome to Natural Healing of Tampa Bay! We look forward to meeting you and also working with you towards your wellness goal. We have enclosed a new patient packet which should be filled out prior to your
To All Mission Ranch Primary Care Patients:
To All Mission Ranch Primary Care Patients: At Mission Ranch Primary Care we strive to provide the best possible customer service. As a part of this, we ask that you fill out this paperwork and return
Workers Compensation Demographic
Workers Compensation Demographic Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave Msg. Email Do
PATIENT INFORMATION. Patient s Name: Birthdate: ( ) F ( ) M LAST FIRST MI. ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed Occupation:
UPON COMPLETION OF PATIENT REGISTRATION PACKET, PLEASE BRING ALL FORMS TO YOUR APPOINTMENT. YOU MAY ALSO FAX COMPLETED FORMS TO THE OFFICE AT 910-575- 9103. THANK YOU. PATIENT INFORMATION Patient s Name:
Norman H. Anderson M.D., P.A. Robert Boissoneault Oncology Institute INSURANCE AUTHORIZATION
Norman H. Anderson M.D., P.A. D/B/A Robert Boissoneault Oncology Institute 2020 SE 17 th Street Ocala, Fl 34471 522 N. Lecanto Highway Lecanto, FL 34461 605 W. Highland Blvd. Inverness, FL 34452 9401 SW
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single
HEALTH QUESTIONNAIRE
emorial City Endocrine Consultants 1140 BUSINESS CENTER DR, SUITE 550, HOUSTON, TEXAS 77043 PHONE: 713-984-8200 FAX: 713-984-1113 Donald F. Gardner, D, FACP Kimberlee K. Perras, NP Ashley. Watson, NP,ANP-BC
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth: Age: Gender: M F Relationship
Patient Name First Middle Last Address Street City State Zip Home Phone Work Phone Cell Phone. Date of Birth SS#
PATIENT WILL NOT BE SEEN WITHOUT PHOTO ID Patient Information Kimberly Walpert, M.D. 1199 Prince Avenue Athens GA 30606 Ph 706-475-1870 Fax 706-475-1879 www.athensbrainandspine.com Patient Name First Middle
MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB. Please answer the following questions about your current eye problems and medical history:
MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB Please answer the following questions about your current eye problems and medical history: 1. What problems are you CURRENTLY having with your
Patient Registration Form
Patient Registration Form Please Complete the Following Information-Thank You Patient Information: Name: Last First MI Address: City: State: Zip: Home Telephone: Work Telephone: Best to Reach? Home? Work?
Health & Safety Packet for Incoming Students
Health Occupations Division 707-256-7600 Health & Safety Packet for Incoming Students This packet has been designed to help Health Occupations students comply with CPR and health/physical documentation
991 Van Houten Avenue Clifton, NJ Phone: Fax: Website: DrLouisVita.com
Louis R. Vita, D.D.S., F.A.G.D. Angelo Colavita D.C., BCAO 991 Van Houten Avenue Clifton, NJ 07013 Phone: 973-777-1933 Fax: 973-777-4727 Website: DrLouisVita.com Email: Vitaoffice991@gmail.com Welcome!
2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults
2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults Complete this form in ink answering all questions. Please print legibly The parent/guardian and camper both must sign this
Patient s Name Home Phone # Last First Middle Would you like reminders sent here? Y N Cell # Address City State Zip
PLEASE PRINT PATIENT REGISTRATION DATE: Patient s Name Home Phone # Last First Middle E-mail: @ Would you like reminders sent here? Y N Cell # Address City State Zip Social Security # Birthdate Sex Marital
Surgery Handbook. ! a GUIDE to PREPARING for your OPERATION Lincoln Circle SE Orange City, IA ochealthsystem.org
Surgery Handbook! a GUIDE to PREPARING for your OPERATION Hospital 712.737.4984 Patient Information 712.737.5238 Toll free: 800.808.6264 Fax: 712.737.5252 1000 Lincoln Circle SE Orange City, IA 51041 ochealthsystem.org
TOS Health Questionnaire
Name Referring Physician Main Reason for Medical Evaluation of Injury/Length of symptoms: Is this a work related problem? Y N Are you right or left handed? Occupation What treatment have you received for
Renée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD
Renée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD RHEUMATOLOGY CONSUTLATION ARTHRITIC CONDITIONS AUTOIMMUNE DISEASES MUSCULOSKELETAL ULTRASOUND Name: First Name Last Name Social Security Number: Sex: