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.
|
|
|
- Cornelia Harmon
- 6 years ago
- Views:
Transcription
1 307 West Central Street Wendy J. Parker, M.D. Natick, MA Deborah J. Riester, M.D. Telephone: Jo-Ann Suna,M.D. Fax: Hadia F. Tirmizi, M.D. Natalia Sedo, N.P. Christine Chang, M.D. Dear New Patient, We would like to take this opportunity to welcome you to our practice and to thank you for choosing our physicians to participate in your healthcare. We look forward to providing you with personalized, comprehensive health care focusing on wellness and prevention. As continuity and coordination of patient care is essential in meeting your healthcare needs, our physicians, nurse practitioner, medical assistants, and office staff work closely in a team approach to support your patient care. Our office is open Monday through Friday from 8:00am-5:00pm. Evening appointments are available every Tuesday until 7:00pm. Every effort is made to see our patients for medical problems during daytime hours. Please note that our schedulers are available every day and will do their best to accommodate you. Booking an appointment is essential to ensuring all patients receive the time they require for quality medical care. After hours care will be provided by the on-call physician, who can be reached by calling our office directly. As your primary care physician, we work collaboratively with Newton-Wellesley Hospital and a wide range of Newton-Wellesley Hospital physician specialists to coordinate all aspects of our patient care including inpatient hospitalization and specialty consultation care, as needed. Before you visit, please notify your health insurance company of your new primary care provider if required. We also request that you contact your previous physician and specialists and request that a copy of your medical record be sent to us. If your former providers are affiliated with the Partners network this should not be necessary. Please fill out the enclosed forms and bring them with you to your appointment. During your initial visit, we will be reviewing your health status and these forms contain information necessary to complete this process. Please bring your health insurance identification card as well as a photo I.D. Please bring a complete list of all of your medications, as well as the strength and dose of each one. Once again, we would like to thank you for choosing us as your primary health care provider. We look forward to working with you. Sincerely, The Providers and Staff of Medical Associates of Greater Boston
2 307 West Central Street Wendy J. Parker, M.D. Natick, MA Deborah J. Riester, M.D. Telephone: Jo-Ann Suna,M.D. Fax: Hadia F. Tirmizi, M.D. Natalia Sedo, N.P. Christine Chang, M.D. Welcome to Your Patient-Centered Medical Home Thank you for choosing us to be part of your health care team. We are committed to providing you the best health care possible by becoming a patient-centered medical home. What is a patient-centered medical home? A patient-centered medical home is a system of care in which a team of health professional s work together to provide all of your health care needs. Our goal is to provide care that is personalized for you. Who is part of my medical home team? Your primary care provider leads your care team. Other members include: Nurse practitioners Nurses Medical assistants Care managers Practice support staff The members of our team act as coaches who help you get healthy and stay healthy and provide the services that are right for you. What Can You Expect? In a patient-centered medical home, we: Help you understand your condition(s) and how to take care of yourself. We explain your options and help you make decisions about your care. We provide you with educational materials specific to your health. Know you and your health history. We know about your personal or family situation and can suggest treatment options that make sense for you. Provide appointments at times that are convenient for you.
3 Address behavioral health issues. Our practice can screen and treat you for behavioral health issues (such as depression) and connect you with other providers. Coordinate care to a trusted specialist, when needed, within Newton- Wellesley Hospital and the Partners Network. Your medical team and specialists work together and share the same electronic medical record system. This allows coordination of care so you can get better faster. Help transfer records from last provider. We can make your transition seamless. Contact us to get started. Patient Portal (for non-urgent communication): Our secure portal allows patients and care teams to interact, before, during and after office hours. Patients can schedule their own non-urgent appointments, medication refills and referrals. The portal allows patients to check lab and test results. After Hours/Urgent Care: A physician is available 24/7 for telephone consultation. Call our office and a physician will be paged for you. Newton-Wellesley Hospital offers Urgent Care in Waltham. The Urgent Care Center is on our electronic medical record system so providers will have access to your medical history and needs. Newton-Wellesley Urgent Care Center Waltham 9 Hope Avenue (Located in the Children's Hospital Building) Waltham, MA We want you to be involved in your health care decisions. How can you help? Be an active team player: Ask health questions so you understand your diagnosis and needs. Communicate with your medical home team. Tell us about your other health care providers, including visits to the emergency department or urgent care.
4 Take care of your health: Collaborate with the team to develop your health care plan. Set reachable goals. Make sure you understand how to follow the plan. Tell your team if you have trouble following the plan or taking your medications. Review the plan and change the goals as needed. Have a checklist for your appointment. Bring a list of your questions with you. Ask the most important ones first. Write down the answers. Before you leave the office, be sure you know what you need to do until your next visit. Office Hours (will get once we know the set up) For appointments, cancellations and prescription refills, please call our office during regular office hours. Patients can also use the Patient Portal to schedule non-urgent appointments at Translation Services If you require a translator, please let us know in advance of your appointment and we will arrange for an interpreter. Need Health Insurance? Apply for health and dental insurance through the Massachusetts Health Connector at We offer equal access to our services regardless of your insurance status.
5 MAOGB MEDICAL HISTORY FORM PATIENT NAME DOB: Do you have any of the following problems? Acid reflux Diabetes mellitus Alcoholism/other addiction(s) Erectile dysfunction Allergies (environmental) Heart disease (specify type: ) Anxiety Hypertension (high blood pressure) Asthma Irritable bowel syndrome) Atrial fibrillation Migraines Cancer (specify type: ) Osteopenia/osteoporosis Coagulation (bleeding or clotting) problem Prostate problem High cholesterol Thyroid problem Chronic low back pain Operation Date Depression Other problems (list below): SURGICAL HISTORY: (Please list all prior operations and dates): I have had no prior surgery. Operation Date Medical Condition Alcoholism Anemia Anesthesia problem Arthritis Asthma Birth defects Bleeding problem Cancer (breast) Cancer (colon) Cancer (skin) Cancer (ovarian) Cancer (prostate) Cancer (other) Colon polyps Depression Diabetes, Type 1 (child) Diabetes, Type 2 (adult) Eczema Epilepsy (seizures) Relation (mother, father, sister) FAMILY HISTORY: Please indicate with a check ( ) family members who have had any of the following conditions: I do not know my family history.
6 MAOGB MEDICAL HISTORY FORM Medical Condition Genetic diseases Glaucoma Hay fever (allergies) Hearing problems Heart attack (CAD) High blood pressure High cholesterol Kidney diseases Lupus (SLE) Mental retardation Migraine headaches Mitral valve prolapse Osteoarthritis Osteoporosis Rheumatoid Arthritis Stroke (CVA) Thyroid disorders Tuberculosis Other: Relation (mother, father, sister)
7 AUTHORIZATION TO RELEASE INFORMATION (Please allow 3-4 weeks for processing) Name: DOB: Phone #: PLEASE OBTAIN INFORMATION FROM: PLEASE SEND INFORMATION TO: Name of Provider/Clinic/Organization Name of Provider/Clinic/Organization Street Address City, State, Zip Code Phone: Fax: Street Address City, State, Zip Code Phone: Fax: I authorize the following information to be disclosed: (Please initial) Entire Record Specific Information REASON for disclosure of this authorization: (Please initial) Continuing Care I will no longer be a patient of Medical Associates Legal Job Other: ADDITIONAL PATIENT INFORMATION: I understand that I have the right to withdraw this authorization. I understand that I do not have to sign this authorization to receive treatment. This request shall remain in effect for 90 days unless specifically revoked in writing; however, such revocation does not affect any actions taken by MAOGB before receipt of the revocation. Failure to fill this authorization out in its entirety and sign will result in a delay and MUST be read completely. I understand that signing this authorization does not cancel any rights I have under the state/federal laws. There may be a processing fee with a maximum fee of $50.00 (Under the privacy rule, medical practices may charge patients a reasonable and cost based charge for copying records. X Date: Client Signature (Legal Representative, if applicable) Relationship **HIV and AIDS information authorization: Specific authorization is required for any HIV-related information. X Date: Client Signature (Legal Representative, if applicable) Relationship **Sensitive Information Authorization: Separate authorization is required to release sensitive information, such as: abortion, substance abuse, genetic information, mental health notes, STD s, rape and abuse. X Date: Client Signature (Legal Representative, if applicable) Relationship
8 Patient Registration Form Patient Information Name: DOB: First Name Last Name ( ) Female ( ) Male Marital Status: SS#: Home Address: Street City/Town Zip Code Home #: Cell#: Work # Preferred # ( ) Home ( ) Cell ( ) Work Emergency Contact Person Name Phone # s Relationship to patient Your Occupation: Preferred Language: Ethnicity: ( ) Hispanic or Latino ( ) Not Hispanic or Latino ( ) Decline Race: ( ) Native American Indian ( ) Asian ( ) Black or African American ( ) White Other ( ) Decline For Gateway Patient Portal Use (Online access to request appointments, refills, receive lab results, etc. For information how to sign-up, please inquire with our staff.) Address: Primary Insurance Carrier Additional Insurance Carrier Name of Insurance Co Name of Insurance Co Name of Subscriber Subscriber s SS# Policy # Group# Name of Subscriber Subscriber s SS# Policy # Group# Subscriber s DOB: Subscriber s DOB: Relationship to Patient Relationship to Patient
9 Referral/PCP: If your insurance company requires you to choose a primary care physician (PCP) it is your responsibility to notify the insurance company that you have chosen your new physician. If you need an insurance referral to see a specialist, you must notify our office before the specialist s visit. If you have an outside PCP, you must obtain a referral for today s visit. Please sign acknowledging your understanding of the above statement and the above information that you have provided is true to the best of your knowledge. Patient/Guardian Date
10 307 West Central St Natick, MA NOTICE OF PRIVACY PRACTICES This notice describes the privacy policies of our practice. Our Obligations: Our office considers your privacy a priority. We follow strict federal and state guidelines to maintain the confidentiality of your protected health information. (PHI). Protected Health Information: Protected Health Information (PHI) is any information about your past, present or future healthcare or payment for that care that could be used to identify you. Members of our workforce and our business associates may only access the minimum amount of protected health information they need to complete their assigned tasks. We may use your PHI in order to treat you, obtains payment for services provided to you and conduct our normal business known as Health Care Operations. Examples of how we use and disclose information include: Treatment We document each visit. This includes test results, diagnosis, medications, and therapies. This allows our staff to provide the best care to meet your needs. Payment We use PHI to obtain payment for services we provide for you. We may tell your health plan about upcoming treatment or services that require prior approval. Health Care Operations We may use PHI in our internal operations in order to improve the quality or care and customer service we deliver to you. Disclosure to Family, Friends and Caregivers We may disclose PHI to a person identified by you, with your verbal or written consent. If you are incapacitated or in an emergency situation, we may exercise our professional judgment to determine whether disclosure is in your best interest. Public Health Activities We may disclose PHI for the following reasons: for public health such as disease tracking; to report abuse or neglect; for coroners or medical examiners; for workmen s compensation; for correctional institutions; for national security; for organ donation; to avoid serious public health or safety threat. Highly Confidential Information the law requires special protections for the following information: HIV/AIDS status; genetic testing; psychiatric information; substance abuse/ controlled substance use; venereal disease; abortion; A separate, specific authorization is required to release this information. You may revoke your authorization at any time. Our Responsibilities -We are required by law to maintain the privacy of your medical information, provide this notice of our duties and privacy practices and abide by the terms of the notice currently in effect. We reserve the right to change privacy practices and to make new practices effective for all information we maintain. New policies will be posted in our office and available from our staff. Your Rights- You have the right to request a restriction on the use of your PHI, however we are not required to abide by the request. You may request that we communicate with you at a specific phone number or address. You may inspect or copy your information, however, this request must be made in writing and a reasonable fee may be charged for copying; you may request that your record be amended, however you must have a reason for the amendment; you have a right to an accounting of the disclosures. This does not apply to disclosures prior to November 30, 2004; you have the right to a paper copy of this notice.
11 If you have any questions about this notice, please contact our privacy officer who is the office manager. If you would like to exercise your rights or feel your rights have been violated, contact the privacy officer. All complaints will be investigated and you will not suffer retaliation for filing a complaint. You may also file a complaint with the department of Health and Human Services in Washington, D.C. Our Office Manager can be reached at Medical Associates of Greater Boston 307 West Central St Natick, MA
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
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
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: 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:
Welcome Letter- Orchard School Clinic
Welcome Letter- Orchard School Clinic Dear Parent or Guardian: Orchard School Clinic is a school-based location of RiverStone Health Clinic. This is a collaborative effort between RiverStone Health, Billings
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
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
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
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
Chandler Family Care 6245 W. Chandler Blvd. #E-4 Chandler, AZ (Phone) (Fax)
Chandler Family Care 6245 W. Chandler Blvd. #E-4 Chandler, AZ 85226 (Phone) 480-940-0088 (Fax) 480-940-9126 I hereby give my consent for Chandler Family Care to use and disclose protected health information
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
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
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)
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
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
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
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
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
DRUG / MEDICATION ALLERGIES: (include: Type/Reaction)
NASSAU CHEST PHYSICIANS PC MEDICAL QUESTIONNAIRE 1 DATE: PATIENT NAME: DOB: DRUG / MEDICATION ALLERGIES: (include: Type/Reaction) 9/1/2014 PHARMACY NAME PHARMACY PHONE PHARMACY Street Address City State
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
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 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
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
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,
Lalita Matta, MD Estrela Chaves, NP, CDE
PERSONAL INFORMATION Name of Patient: Maiden Name: Social Security No.: Date of Birth: Home Address: City: State: Zip: Home Phone: Mobile Phone: Work Phone: Email Address: Race/ Ethnicity: Marital Status:
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:
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,
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 REGISTRATION FORM (ecw)
PATIENT INFORMATION PATIENT REGISTRATION FORM (ecw) (Please print) Patient s Name: (Last) (First) (MI) Address: City, State, Zip: Home: Cell: Work: E-Mail Address: DOB: Sex: Female Male Transgender Race:
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
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
City. Whom may we thank for referring you to us?
CAMBRIDGE DENTAL CENTER - PATIENT REGISTRATION Date Patient's Last Name First :Kame MI Age Soc. Sec. No.: Home Work Phone: Home rujul
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
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:
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
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
School Based Oral Health Services
Seal a Smile Oral Health Program A project of Whitney M. Young Jr. Health Services and the Healthy Capital District Initiative School Based Oral Health Services Oral health classroom education Dental screenings
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
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
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
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
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
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
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:
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:
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
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
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
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
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you
School Based Health Consent for Services Grace Community Health Center, Inc.
School Based Health Consent for Services Grace Community Health Center, Inc. Please read carefully: In order for us to see your child in school based clinics, all pages of this form must be completed by
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:
Fax: Do not mail the forms!
Associates in Pediatric and Adult Urology The Morristown Medical Center Health Pavilion 333 Mount Hope Avenue Suite 250 Rockaway, NJ 07866 973-895-6636 Dear New Patient: Welcome to Associates in Pediatric
NORTHSIDE PARK GASTROENTEROLOGY & ENDOSCOPY CENTER, PLLC
NORTHSIDE PARK GASTROENTEROLOGY & ENDOSCOPY CENTER, PLLC PATIENT REGISTRATION Today s Date: / / Birthdate: / / S.S. # / / Patient Name: Age: Sex: Last First MI Address: City: State: Zip Code: Home Phone:
Dear New Patient: Sincerely, The Scheduling Staff
Dear New Patient: Welcome to Garden State Urology. The physicians in our group are board-certified, fellowship trained urologists who provide stateof-the-art care that rivals the finest academic institutions
Dear Kaniksu Patient,
Dear Kaniksu Patient, Welcome to Kaniksu Health Services (KHS), a Community Health Center that provides quality and affordable medical, pediatric, dental, behavioral health and veteran care, regardless
MAIN STREET RADIOLOGY
MAIN STREET RADIOLOGY PATIENT REGISTRATION FORM **OFFICE USE ONLY** TODAY S DATE: MR#: LAST NAME: FIRST NAME: ADDRESS: APT: CITY: STATE: ZIP CODE: HOME PHONE #: ( ) - CELL PHONE#: ( ) - DATE OF BIRTH:
Welcome and thank you for choosing Jerman Family Dentistry
Welcome and thank you for choosing Jerman Family Dentistry We provide dental services for the entire family. The following is helpful information to serve you better as a patient. If there are questions
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
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 # -----
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
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
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
NEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone. Address: Driver s License #:
Patient s Name: NEW PATIENT PACKET Last Middle First Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone Email Address: Driver s License #: DOB: Gender: Male Female
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
WELCOME TO OUR OFFICE!
WELCOME TO OUR OFFICE! Name Date: / / Address City State Zip Home Phone Cell Phone E-Mail Birthdate Age SS# Race: Marital Status: M W D S Employer Work Phone Occupation Name & Birthdate of Primary Insured
Independent Wellness Center 1000 W. Apache Trail, Suite #108, Apache Junction, AZ Phone# Fax #
PATIENT INTAKE Welcome t o Independent Wellness Center. In order to provide you with the best health care and assist you with other details of our clinic, we have provided the following information. We
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 #:
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 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
Thank you for choosing Smileology for your implant, cosmetic and family dentistry needs!
Thank you for choosing Smileology for your implant, cosmetic and family dentistry needs! Please complete the attached health record prior to your arrival. By choosing us, you have selected a practice whose
Welcome to Mid-State Health Center. Our Promise to You. Locations and Hours. After-Hours Access
101 Boulder Point Drive, Suite 1 Plymouth, NH 03264 603-536-4000 www.midstatehealth.org Welcome to Mid-State Health Center Mid-State Health Center looks forward to working with you and your family. Your
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: - -
107 Commercial Street Mashpee, MA (fax)
107 Commercial Street Mashpee, MA 02649 508-477-7090 508-477-7028 (fax) www.chcofcapecod.org Welcome to your new medical home! We are excited to offer you high quality, integrated health care services
Bring your insurance card(s) and a picture identification card to your appointment.
Your appointment is on / / at :. Thank you for choosing Midwest Ear Specialists (a member of the BJC Medical Group) as your healthcare partner. We value communication, beginning with the new patient registration
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
School Based Health Services Consent Form
MRN: PCP: Teacher: Grade: School Based Health Services Consent Form Before your child sees a provider, we are asking you to authorize medical and/ or dental treatment. We will work with you to improve
Practice Limited to Infants, Children, & Adolescents
Practice Limited to Infants, Children, & Adolescents 9290 SE Sunnybrook Blvd., #200, Clackamas, OR 97015 (503) 659-1694 5050 NE Hoyt St., #B55, Portland, Oregon 97213 (503) 233-5393 16144 SE Happy Valley
Date. Dear. Thank you for scheduling your appointment with us on to welcome you to Lighthouse Family Medicine.
Date Dear Thank you for scheduling your appointment with us on to welcome you to Lighthouse Family Medicine.. It is our pleasure Enclosed you will find a new patient information packet. Please complete
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
Patient s Legal Name: Preferred Name: First Middle Last
Douglas County Dental Clinic Patient Registration Revised August 2016 We REQUIRE A Parent, Guardian, Or Other Legally Responsible Party To Complete & Sign all forms. Please provide a photo ID, Proof of
INFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of client) agree and consent to participate in behavioral healthcare services offered and provided by Methodist Services - Community Counseling Services (CCS). I
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
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
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
School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax:
Dear Parents/Guardians: School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE 19807 Phone: 651-2100 Fax: 651-2111 The Wilmington Charter/Cab Calloway
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
PATIENT'INFORMATION'!
PATIENT'INFORMATION'! ' Referred By: Date: PharmacyName,PhoneLocation: LastName: FirstName: MiddleName: DateofBirth: Gender: SSN: MaritalStatus: DriversLicense: PrimaryLanguage: Race: _ AmericanIndian/AlaskaNative
PATIENT INFORMATION. Last Name: First Name: MI: Date of Birth: SS #: Gender: Male Female. City: State: Zip Code:
PATIENT DEMOGRAPHIC FORM PATIENT INFORMATION Last Name: First Name: MI: Date of Birth: _ SS #: Gender: Male Female Address: Apt. #: City: State: Zip Code: Home Phone: ( ) - Cell Phone: ( ) - E-mail: Marital
Patient Name: First Middle Last Address: City: State: Zip Code: Date of Birth: Social Security: Marital Status: S M D W
Date: Sex: M or F Patient Name: First Middle Last Address: City: State: Zip Code: Date of Birth: Social Security: Marital Status: S M D W Home Phone: Work Phone: Cell Phone: Email Address: Employment Status:
MICHELE S. GREEN, M.D.
MICHELE S. GREEN, M.D. Name Last First Middle initial Address Number Street Apt# City, State Zip Home Cell Email Please Circle: Preferred Contact Number Home Cell Work Single Married Divorced Widowed Male
HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.
Today date: HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed. Patient Full Name: Of Birth: Street: City: Zip Code:
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
PATIENT INFORMATION. ETHNICITY: (Please circle one) Hispanic or Latin, Not Hispanic or Latin, Refuse to Report
PATIENT INFORMATION NAME: DOB: AGE: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL: WORK: *Please list your email address for the patient portal. It will not be used for any commercial communication. RACE:
James M. Wilson, M.D. - Medical Information to (fax to ) PATIENT INFORMATION Last name: First: D.O.
James M. Wilson, M.D. - Medical Information Email to wilson@houstonmds.org (fax to 713-790-1605) PATIENT INFORMATION Last name: First: D.O.B: SSN: Age: Gender: M F Home Phone #: Cell Phone #: Work Phone
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:
351 Osborne Road, Loudonville, New York ARWynnykiwDDS. Welcome!
351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS www.albanydds.com Welcome! When it comes to dentists, I know that you have many options. My goal
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#:
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
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: