BROOKLINE VILLAGE OBGYN PATIENT INFORMATION SHEET PLEASE COMPLETE ALL INFORMATION
|
|
|
- Aubrey Wilcox
- 5 years ago
- Views:
Transcription
1 BROOKLINE VILLAGE OBGYN PATIENT INFORMATION SHEET PLEASE COMPLETE ALL INFORMATION PATIENT: Date: Last Name Address First Name City Middle State Zip Date of Birth Social Security # Phone # Cell # Marital Status: Single Married Employer Widowed Divorced Emp. Address City State Occupation Zip Phone HUSBAND: (or any other party responsible for payment besides patient) Last Name Address First Name City State Middle Zip Date of Birth Phone # Social Security # Employer Relationship to Patient Address Occupation City State Zip Phone REFERRAL SOURCE: INSURANCE INFORMATION: Primary Insurance Policy # Billing Address Subscriber Group# Secondary Insurance Policy # Billing Address Subscriber Group #
2 Brookline Village OBGYN New Patient Questionnaire Name: DOB: / / Address: Phone- Home: Cell: Work: Enrolled in Patient Gateway: [ ] Yes [ ] No Reason for visit: Reproductive History: Total # of pregnancies: # of Miscarriages: Date of delivery/outcome or complication/baby Name/Birth weight/vaginal or C/Section: 1:_ 4: 2:_ 3:_ 5: 6: Have you had problems getting pregnant? [ ] Yes [ ] No If yes, please explain Last Menstrual Period: / / Age at 1 st menstrual period: How often is your period? # days of menstrual flow: Is your flow: [ ] Heavy [ ]Moderate [ ] Light If your period is painful, is the pain: [ ] Mild [ ] Moderate [ ] Severe List all contraceptive types used in the past: When was it last used? Do you experience problems with intercourse? (i.e. pain, lack of lubrication, low libido) Date of last Pap smear / / Did you ever have an abnormal Pap? [ ] Yes [ ] No If abnormal, please list what kind of treatments you received and dates Have you ever tested positive for HPV? [ ] No [ ] Yes If yes, when Did you receive the Gardasil vaccine? [ ] No [ ] Yes If yes, please list approximate dates Have you ever been diagnosed with an STD? [ ] No [ ] Yes If yes, please circle: Herpes, Genital warts, Chlamydia, Gonorrhea, Trichomonas, Syphillis, Hepatitis B or C, HIV. Please list treatments and dates: Did your mother take DES when she was pregnant with you? [ ] Yes [ ] No
3 Brookline Village OBGYN New Patient Questionnaire Personal Medical History: (check and explain) [ ] Neurologic (headache, migraines, seizures) [ ] Heart Disease/ High blood pressure/ Murmur [ ] Breathing Problems/ Asthma/ Tuberculosis [ ] Thyroid problems [ ] Diabetes [ ] Depression/Anxiety [ ] Hepatitis/Jaundice [ ] Stomach problems [ ] Intestinal problems [ ] Kidney problems (stones, infections) [ ] Chronic pain/ Joint problems [ ] Anemia [ ] Bleeding or clotting problems [ ] Autoimmune disease/ Lupus [ ] Skin disorders [ ] Breast problems [ ] Cancer Past Surgeries (with dates): Drug Allergies with reactions: Medications: (current with dosages) Immunizations: (please list dates if known) Influenza: Tdap: Varicella: MMR:
4 Brookline Village OBGYN New Patient Questionnaire Family History (please list age and medical problems): Mother: Father: Siblings: Maternal Grandparents: Paternal Grandparents: Any congenital defects or syndromes? [ ] No [ ] Yes Any mental retardation? [ ] No [ ] Yes Ethnicity: Habits: Do you smoke? [ ] Yes [ ] No Have you ever smoked? [ ] Yes [ ] No If yes, how much? How many alcoholic drinks per week? Any other drugs (cannabis, cocaine, heroin, prescription drugs)? Exercise? Special diet? Social History: Marital status (circle): Single Married Divorced Widowed Occupation: Cats: [ ] No [ ] Yes Do you empty the litter box? [ ] No [ ] Yes Partner s age: Occupation: _ Partner s ethnicity: Any health problems? Any history of domestic violence? [ ] Yes [ ] No Do you currently feel safe? [ ] Yes [ ] No Primary Care Physician: Name Phone
5 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Brookline Village OB/GYN Jeffrey E. Katz, M.D. Carolyn A. Cline, M.D. Tracy R. Zinner, M.D. Joan S. Hier, M.D. Barbara S. Frank, M.D. One Brookline Place, Suite 620 Brookline, MA Phone: (617) Fax: (617) PATIENT INFORMATION Name: Date of Birth: Address: Phone Number: I HEREBY AUTHORIZE BROOKLINE VILLAGE OB/GYN TO: Release my records to Myself Release my medical records to: Obtain my medical records from: Name/Facility: Phone: Address: Fax: City: State: Zip Code: INFORMATION TO BE RELEASED Entire Record Past 5 years Only those items checked below: History & Physical Laboratory Tests Radiology Reports (i.e. Ultrasounds, Mammograms, etc.) HIV Status/STD Screening Other: (please specify) Print Name Signature Date
6 BROOKLINE VILLAGE OBGYN ONE BROOKLINE PLACE, SUITE 620 BROOKLINE, MA (617) RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM I,, have received a copy of Patient Name Brookline Village OBGYN s Notice of Privacy Practices. _ Print Patient s Name Date of Birth _ Patient s Signature Date signed _ Signature of Patient or Patient s Representative Patient Relationship to
7 BROOKLINE VILLAGE OBGYN ONE BROOKLINE PLACE, SUITE 620 BROOKLINE, MA (617) THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Understanding Your Health Record/Information Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a: --basis for planning your care and treatment --means of communication among the many health professionals who contribute to your care --legal document describing the care you received --means by which you or a third-party payer can verify that services billed were actually provided --tool in educating health professionals --source of data for medical research --source of information for public health officials charged with improving the health of the nation --source of data for facility planning and marketing --tool with which we can assess and continually work to improve the care we render and the outcomes we achieve. Understanding what is in your record and how your health information is used helps you to: --ensure its accuracy --better understand who, what, when, where, and why others may access your health information --make more informed decisions when authorizing disclosure to others.
8 Your Health Information Rights Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to: --request a restriction on certain uses and disclosures of your information as provided by 45 CFR This request must be made in writing. We are not required to agree to this request. --obtain a paper copy of this notice of information practices upon request --inspect and obtain a copy of your health record as provided for in 45 CFR This request must be made in writing and with your signature. --amend your health record as provided in 45 CFR This request must be made in writing with reasons given for the amendment. --obtain an accounting of disclosures of your health information as provided in 45 CFR This request must be made in writing and indicate a limited time period for the accounting. --request communications of your health information by alternative means or at alternative locations. This request must be made by written request. We will accommodate reasonable requests. --revoke your authorization to use or disclose health information except to the extent that action has already been taken. --provide an authorization for other uses and disclosures not identified by this notice. Our Responsibilities This organization is required to: --maintain the privacy of your health information --provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you --abide by the terms of this notice --notify you if we are unable to agree to a requested restriction --accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
9 We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will make available to you a revised notice. We will not use or disclose your health information without your authorization, except as described In this notice. Examples of Disclosures for Treatment, Payment and Health Operations We will use your health information for treatment. For example: Information obtained by a nurse, physician, or other member of your healthcare team Will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will record the actions he or she took and his/her observations. We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying The bill may include information that identifies you, as well as your diagnosis, procedures and supplies used. We will use your health information for regular health operations. For example: Members of the medical staff or quality assurance manager may use information in your health record to assess the care and outcomes in your care and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. Other Permitted or Required Uses and Disclosures Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, and certain laboratory tests. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information. Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care. Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
10 Health Management: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacement. Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. For More Information or to Report a Problem If you have questions and would like additional information, you may contact Brookline Village OBGYN at (617) If you believe your privacy rights have been violated, you can file a complaint with our office or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
11 JEFFREY E. KATZ, M.D. CAROLYN A. CLINE, M.D. TRACY R. ZINNER, M.D. JOAN S. HIER, M.D. BARBARA S. FRANK, M.D. ONE BROOKLINE PLACE, SUITE 620 BROOKLINE, MA I authorize the release of my medical or other information necessary to process this claim. I also request payment of benefits either to myself or to Dr. Jeffrey E. Katz, Dr. Carolyn A. Cline, Dr. Tracy R. Zinner, Dr. Joan S. Hier, or Dr. Barbara Frank. Print Patient s Name Date of Birth Date Signed Signature of Patient or Patient s Representative Relationship to Patient Print Name of Patient s Representative I authorize payment of medical benefits to Dr. Jeffrey E. Katz, Dr. Carolyn A. Cline, Dr. Tracy R. Zinner, Dr. Joan S. Hier, or Dr. Barbara Frank for services provided at the address above and the Brigham and Women s Hospital. Print Patient s Name Date of Birth Date Signed Signature of Patient or Patient s Representative Relationship to Patient Print Name of Patient s Representative
Responsible Party (Guarantor) Info. Insurance Information
Associates in Women s Health, P.C. 2801 YOUNGFIELD STREET, SUITE 200 GOLDEN, CO 80401 P: 303-940-1867 F: 303-940-1894 Please Circle Your Doctor: ELLIS GANTER PYTHON SCHOEN WESSELL, WHNP PATIENT INFORMATION
Welcome to Hawaii Women s Healthcare
Cheryl Lynn T. Rudy, M.D. Cheryl L. Leialoha, M.D. Erin C. Gertz, M.D. Laura A. Spector, D.O. Andrea Wieland, APRN Welcome to Hawaii Women s Healthcare Hawaii Women s Healthcare strives to provide you
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
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
SANTA RITA CARE CENTER Notice of Information Practices
SANTA RITA CARE CENTER Notice of Information 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
INSURANCE INFORMATION
2014 575 Hill Country Dr. Ste 202 Kerrville, TX 78028 (830)258-6237 Office (830)315-1366 Fax Patient Name (last, first, MI) of Birth Social Security Number Mailing Address Home Telephone Work Telephone
PATIENT INFORMATION. In Case of Emergency Notification
PATIENT INFORMATION Patient Name Date Nickname DOB Age Sex Race/Ethnicity Language(s) spoken at home Person completing form Relation to Patient Patient Address City State Zip Phone # Other Phone Medical
Sage Medical Center New Patient Forms
Sage Medical Center New Patient Forms Patient Name: DOB: Providers and Suppliers of Your Medical Care: Please list all providers and suppliers of your medical care such as primary care physicians, specialty
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:
Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:
Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married
The process has been designed to be user friendly and involves a few simple steps.
HOW DO I ENROLL A PATIENT WITH HOUSECALL MD? The process has been designed to be user friendly and involves a few simple steps. It is the patient s/family s/dpoa s/guardian s decision, if they want to
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
Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:
5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:
PATIENT'REGISTRATION'FORM'FOR'KURT'R'WHARTON S'OFFICE' ' Last%Name:% %%%%%%%%%%%First%Name:% %%%%%%%%%%%%%%Middle:% %% % Responsible%Party:%
PATIENT'REGISTRATION'FORM'FOR'KURT'R'WHARTON S'OFFICE' ' LastName: FirstName: Middle: ResponsibleParty: Relationship: Address: Zip: City: State: PreferredPhone: Email: MaritalStatus: S M D W LegallySeparated
The Home Doctor. Registration Checklist
The Home Doctor Registration Checklist All enrollees: ( ) Enrollment Form ( ) Copy of Insurance card(s) ( ) Medication List ( ) POA/Guardianship documents NOTICE Please allow two weeks for processing this
**IF YOU SHOW UP WITHOUT ANY OF THE LISTED ITEMS, WE WILL RESCHEDULE!!!**
Dr. Jasna Kojic 6000 Turkey Lake Rd. Suite 205 Orlando, FL 32819 PHONE: (407) 649-1848 FAX: (407) 649-1979 Dear Parent/Guardian of : We welcome you and your son/daughter to our office and are happy to
Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL
Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL 32789 407-647-1331 Name Date Email @ Please Circle One: Ethnicity: Hispanic or Latino American/White Not Hispanic or Latino Unknown
2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name
Patient Information 2201 Murphy Avenue, Suite 307 Nashville, TN 37203 Phone 615-401- 9454 Fax 615-873- 1934 www.robbinsplasticsurgery.com Date Patient s Full Name Last First M.I. Preferred Name (if different
Dear New Patient, Once again, we would like to thank you for choosing us as your primary health care provider. We look forward to working with you.
307 West Central Street Wendy J. Parker, M.D. Natick, MA 01760 Deborah J. Riester, M.D. Telephone: 508-820-8383 Jo-Ann Suna,M.D. Fax: 508-820-0250 Hadia F. Tirmizi, M.D. Natalia Sedo, N.P. Christine Chang,
NEW BRIGHTON CARE CENTER
NEW BRIGHTON CARE CENTER 805 6 th Ave NW, New Brighton, MN 55112 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
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
Page 1 of 5 1/4/17. Print Guardian Name (If not patient) DOB: Circle One: - - Patients Name: (Last, First, MI):
Patients Name: (Last, First, MI): SSN: DOB: Circle One: Male Mailing Address: Apt. #: City: State: Zip Code: Female Race: Ethnicity Primary Language: Home Phone: Preferred? Cell Phone: Preferred? Employer:
PATIENT INFORMATION Indiana Plastic Surgery Center, PC
PATIENT INFORMATION DATE: / / PHYSICIAN REFERAL: FAMILY/FRIEND REFERAL: PRIMARY CARE PHYSICIAN: LAST NAME FIRST M.I. HOME ( ) - CELL( ) - WORK( ) - EMAIL MAY WE CONTACT YOU: BY CELL PHONE / TEXTING?: YES
ALFRED ALINGU, MD INTERNAL MEDICINE
Name Date of Birth Social Security Number Marital Status Address City State Zip Code Home Phone Cell Phone E-mail Address Pharmacy Name Pharmacy Phone Number Emergency Contact Phone Number Relationship
PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX
PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D. 1506 KLONDIKE RD SW SUITE 205 CONYERS, GA 30094 678-750-4000 TELEPHONE 678-750-4005 FAX www.pcfwellness.com Dear Family, We are excited to welcome
Choptank Community Health System Caroline County School Based Health Centers Healthy Children Are Better Learners MEDICAL
Choptank Community Health System Caroline County School Based Health Centers Healthy Children Are Better Learners MEDICAL Dear Parent/Guardian: As a student in the Caroline County Public School system,
Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801
How did you hear of our office? New Patient Registration SECTION 1: PATIENT INFORMATION Patient Name: M / F Date of Birth: Address: City: State: Zip Code: SECTION 2: PARENT / GUARDIAN / INSURANCE Name:
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
Medical History. Patient Information. Dental History. Your current physical health is: Good Fair Poor
Medical History Your current physical health is: Good Fair Poor Cruse Dental Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin,
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
NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE
REGISTRATION (please print) PATIENT INFORMATION DATE: NAME SS# ADDRESS CITY STATE ZIP TELEPHONE (home) (business) Cell Email SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE MOTHER'S FIRST NAME
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
Seasons Women s Care Patient Registration Form
Seasons Women s Care Patient Registration Form Name: of Birth: Address: City: St: Zip Home Phone: Cell: Best Number: Email: Race or Ethnicity: Marital Status: SS# Drivers Lic#: Employer: Work# Occupation:
Women s Center. Ocala Abortion Clinic 108 NW Pine Avenue Ocala, FL Ph: (352) Toll Free: (877)
Orlando Abortion Clinic 1103 Lucerne Terrace Orlando, FL 32806 Ph: (407) 245-7999 Toll Free: (877) 692-2273 EPOC Abortion Clinic 609 Virginia Drive Orlando, FL 32803 Ph: (407) 898-2046 Toll Free: (877)
Print Guardian Name (If not patient) DOB: Patients Name: (Last, First, MI): Circle One: - - / / Mailing Address: Apt. #: City: State: Zip Code:
Patients Name: (Last, First, MI): SSN: DOB: Circle One: Male Mailing Address: Apt. #: City: State: Zip Code: Female Race: Ethnicity Primary Language: Home Phone: Preferred? Cell Phone: Preferred? Employer:
Broomall Patients ONLY may send forms via to:
Thank you for choosing Children s Dentistry! To expedite your check in, please complete the forms in this packet and bring with you to your appointment. You may also FAX these forms to the office where
ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION
Patient Name (PLEASE PRINT): Date of Birth: ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION The & Center of Southern Oregon, PC s Notice of Privacy Practices contains information about the uses and disclosures
NOTICE OF INFORMATION AND PRIVACY POLICIES FOR KAREN P. FREED, LCSW-C, BCD WHIPPOORWILL LANE NORTH BETHESDA, MARYLAND
NOTICE OF INFORMATION AND PRIVACY POLICIES FOR KAREN P. FREED, LCSW-C, BCD 12007 WHIPPOORWILL LANE NORTH BETHESDA, MARYLAND 20852 301-816-0978 THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED
Pediatric Patient History
Pediatric Patient History Childs Name: Today s Date: Primary Doctor: Date of Birth: Age: Reason for visit: List all chronic medical problems: List all medication dosages and frequency taken (including
Crescent Community Clinic Application for Healthcare Services
Crescent Community Clinic Application for Healthcare Services If you have been diagnosed with a dental concern, a chronic health or mental health condition, you may be eligible for free healthcare at the
DECLARATION AND CONSENT TO TREATMENT
3160 Steeles Avenue East, Suite 204 Markham, ON L3R 4G9 T. 905.477.0200 F. 905.477.0028 E. info@mnhc.ca W. www.mnhc.ca DECLARATION AND CONSENT TO TREATMENT Patients Name _ Date City Province Postal Code
POTS Treatment Center 7515 Greenville Avenue, Suite 1005 Dallas, TX
Patient Registration: POTS Treatment Center 7515 Greenville Avenue, Suite 1005 Dallas, TX 75231 214-369-8717 Date: Briefly state the medical problem for which you made this appointment today : Name : Address:
PATIENT INFORMATION. Patient's Legal Name Birth Date S.S. # Last First Middle Marital Address Daytime Phone # ( ) Status Street City Zip Area Code
VALERIE SCHOLTEN, M.D. NEW PATIENT NEW OB NAME CHANGE ADDRESS CHANGE INS. CHANGE UPDATE Most insurance carriers require us to submit claims for patient services. For this reason, we request all patients
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
R. B. KO L A C H A L A M M. D. GENERAL SURGERY
GENERAL SURGERY Patient Information (Please Print and Circle or check the appropriate response) Patient s Name: DOB: _ Address: City: _ Zip: Home Phone: Cell: Work:_ Email Address: Patient s SSN: Male
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 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
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
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,
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
Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?
Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic
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
PATIENT INFORMATION When registering please provide proof of insurance and Picture ID Payment is expected at time of service.
KENTUCKY FERTILITY, GYNECOLOGY AND OBSTETRICS PRIMARY HEALTH CARE 170 North Eagle Creek DR Suite 101 Lexington KY 40509 Phone 859-277-5736 Fax 859-276-2236 PATIENT INFORMATION When registering please provide
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: - -
New Patient Intake Form
Phone: (336) 538-0089 Fax: (336) 538-0097 Burlington, NC 27253 New Patient Intake Form Provider: Dr. Martin DeFrancesco Melody Burr Lindsey Overton Patient Name: DOB: Marital Status: Single Married Divorced
Kent State University Health Services. Medical History Form
Kent State University Health Services Medical History Form 1. This form must be returned to the Student Health Service prior to being seen at UHS. 2. This form will become a part of the Student Medical
Columbia Medical Practice- Pediatrics Ken Klebanow M.D. and Associates
HOWARD COUNTY HEALTH DEPARTMENT SCHOOL-BASED WELLNESS CENTERS PROGRAM TELEMEDICINE SERVICES A partnership between the Howard County Health Department and the Howard County Public School System What is
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 REGISTRATION
of Appointment: Referring Physician: Denton Watumull, M.D. Derek Rapp, M.D. Joshua Lemmon, M.D. Chase Derrick, M.D. Submit completed form to your patient coordinator s email, print out or email to: Bruce
Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self
Patient Information (Please Print) Dr. Miss Mr. Mrs. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP)
PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE (MR: )
PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE DATE: (MR: ) Office Use Only PATIENT S NAME: (FIRST, MIDDLE INITIAL, LAST) DATE OF BIRTH AGE SOCIAL SECURITY # MALE/FEMALE ADDRESS
(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:
Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?
Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic
School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE Phone: Fax:
School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE 19720 Phone: 324 5740 Fax: 324 5745 Dear Parents/Guardians: The William Penn School Based Health Center (SBHC) is a
Patient Name Age Date of Birth. Patient Address. City State Zip Code. Home Phone Cell Phone Work Phone
Patient Registration Date Patient Information Patient Name Age Date of Birth Patient Address City State Zip Code Home Phone Cell Phone Work Phone Last 4 Digits of Your Social Security Number Email Marital
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! Please fill out this form as completely as possible and return it to the desk.
Welcome to our office! Please fill out this form as completely as possible and return it to the desk. Name of Doctor you wish to see: Today's Date Name Email Address Address Home Male Female Cell City
CURE CARDIOVASCULAR CONSULTANTS
NEW PATIENT PACKET There are six pages in this packet that will help us get a clearer picture of your medical history and physical health. Please note: SIGNATURES are required on pages 2, 4, and 6. Please
Welcome! 2128 Spears Rd, Suite 300 Houston, TX 77067~ Fax: ~ Rev 3/20/14
Welcome! Welcome to Premier Pediatrics of Houston! We are very excited that you have chosen us, and we are confident that you will be very pleased with the service and care we provide to your family. Please
Fulcrum Orthopaedics Patient Registration Packet
Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 9 Consent for Use and Disclosure of Information 10 Authorization for Use and Disclosure of Protected Health Information 11 Notice
ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient
Welcome to the Office of Dr. Sam Van Kirk!
Welcome to the Office of Dr. Sam Van Kirk! We understand that you have a choice in selecting your healthcare provider and we are pleased that you picked our practice. Our goal is to provide respectful,
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
PATIENT INFORMATION INSURANCE INFORMATION. (Please give your insurance card to the receptionist.) Address (if different): IN CASE OF EMERGENCY
CLINICA PRENATAL SAN JOSE, INC. REGISTRATION FORM Today's date: PCP: PATIENT INFORMATION Patient's last name: First: Middle: Mr. Mrs. 0 Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid
We welcome you as a patient
St. Augustine Cardiology Associates, P.A. Ferris E. George, M.D. Robert N. Signor, M.D. Billie J. Russell, PhD, ARNP-BC Susan W. Morrow, ARNP 201 Health Park Blvd., Suite 105 St Augustine, FL. 32086 904-824-1776
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 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
Dr. Kinsler & Associates, LLC Help when life hurts
Dr. Kinsler & Associates, LLC Help when life hurts PREMARITAL COUNSELING INTAKE Bride s Name: WEDDING DATE: Age: Birthdate: Birthplace: Address: City: State: Zip: Phone: Highest level of education (grade/degree):
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Name: E-Mail: New Patient? Previous Patient? Previous name if different: Age: Date of Birth: Social Security #: Sex: Female Male Marital Status: S M W D Home Address: City: State:
Social Security Number: Employment Status: Employed Unemployed Address: Student Retired
Please complete all forms fully and to the best of your ability. If something does not apply to you please write N/A in the field. Patient Demographics: Name: Sex: Male Female Address: Apt: City: Marital
Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:
New Patient Office Information Last Name: First Name: Initial Date of Birth: SSN # Marital Status: Single Married Divorced Widowed Address: City: State: Zip: Gender: M Parent/ Legal Guardian if Patient
1. Severity? (0-10) Duration? 2. Severity? (0-10) Duration? 3. Severity? (0-10) Duration?
Stefan M. Herold, DC, DACNB Tiferet Chiropractic Neurology @ Portland Natural Health - 1221 SE Madison St., Portland OR 97214 - Phone: (503) 445-7767 PATIENT INFORMATION (Please answer all questions, circle
Form B - For those enrolled in other insurance
Form B - For those enrolled in other insurance PATIENT REGISTRATION Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth
Medical History Form
Medical History Form Patient Name of Birth Medical History Do you have or have you had any of the following? Condition Yes No Condition Yes No Condition Yes No ADHD Stroke Menopausal Syndrome Allergies
at with. (Date) (Time) (Physician)
Dear Lombardi Patient: Georgetown University Hospital s physicians and staff would like to welcome you and thank you for choosing the Lombardi Comprehensive Cancer Center for your care. Our goal is to
*Family Chiropractic Care* New Patient Information Worksheet*
*Family Chiropractic Care* New Patient Information Worksheet* Name: SSN: Age: Address: City: State: Zip: Phone Hm: Wk: Date of Birth: E-Mail Employer: Insurance: Policy/I.D. # : Spouses Name: Marital Status:
Your appointment is with:
380 HOSPITAL DRIVE, SUITE 320 MACON, GA 31217 233 NORTH HOUSTON ROAD, SUITE 140F WARNER ROBINS, GA 31093 Office Phone: (478)742-5331 Office Fax: (478)750-1387 www.seurology.com W. Winston Wilfong, MD Lancing
Welcome to Doctors of Internal Medicine, your new Medical home!
Welcome to Doctors of Internal Medicine, your new Medical home! The Patient-Centered Medical Home is a team-based approach to providing comprehensive primary care. The PCMH is a health care setting that
Patient Information Form
Patient Information Form Full Name: Date of Birth: / / Gender: M or F SS#: Marital Status: Single Married Widowed Divorced Employment Status: Employed Unemployed Retired Disabled Address: City: State:
Revised 4/28/2015 Crescent Community Clinic Application for Healthcare Services
Application for Healthcare Services Adults, ages 18 to 64 with no health insurance and limited income you may be eligible for free healthcare at the if you have a chronic health condition, been diagnosed
Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:
SALT LAKE EYE ASSOCIATES, LLC (801) 281-2020 1025 E 3300 S, SLC, Utah * Patient Information Sheet First Name: Last Name: Middle Initial: Referred By Family Doctor EMAIL Street Address: City: State: Zip:
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
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
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c N E W P A T I E N T I N T A K E F O R M Print Name Today s Date Address City State Zip Email Address Date of Birth Male Female Social Security
From: AR Center (Arkansas Center for the Study of Integrative Medicine)! PLEASE READ FIRST!!
From: AR Center (Arkansas Center for the Study of Integrative Medicine) PLEASE READ FIRST Please be sure that you have a QUALIFYING MEDICAL CONDITION for Medical Marijuana in Arkansas. If you do not have
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?
Women s Specialty Care, P.C 682 Hemlock Street Suite 300 Macon GA WELCOME
Women s Specialty Care, P.C 682 Hemlock Street Suite 3 Macon GA 3121 478-744-9683 WELCOME Thank you for choosing Women s Specialty Care, P.C. for your OB/GYN needs. We ask that you complete all of the
PATIENT INSTRUCTIONS FOR PAPERWORK
330 Mallory Sta-on Rd., Suite B3 Franklin, TN 37067 Ph. 615-944-3530 Fax. 615-550.2641 PATIENT INSTRUCTIONS FOR PAPERWORK Thank you so much for trus0ng your care to Integra0ve Family Medicine. A
Thank you, in advance, for being a partner in your care.
477 Cooper Road, Suite 220 Westerville, OH 43081 614-818-0215 Your appointment with: Dr. David H. Brown Dr. Jed W. Henry Dr. Adam J. Clemens is scheduled for. Welcome to our practice. It is our desire
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#: