We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal."

Transcription

1 Appointment Date: Appointment Time: Dear Orion Member, We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal. Enclosed you will find our new patient paperwork. In order to minimize your wait, please take a few moments to complete the enclosed forms and bring it with you to your appointment. This is so we can better assist you with your healthcare needs. On the first day of your evaluation you will need to bring your enthusiasm and a positive attitude, we provide the rest. Again, thank you for your interest and we look forward to working with you! GOOD LUCK! Sincerely, Dr. Kroll and the Orion Staff

2 Welcome to our practice! Please Note: The first visit will take approximately 45 minutes to 1 hour. Please allow 24 hours notice for any cancellations. Being more than 15 minutes late to an appointment will result in rescheduling. New patients must bring a U.S. government approved I.D. For your convenience we accept cash, check, and credit cards. Payment for the evaluation is due at the time of service. Payments for all subsequent weigh-ins are due at the first visit of the week. All other visits for that week are included. We do not accept any insurance but some insurance companies do cover weight loss treatments. There is paperwork available that you may submit for repayment, but it is up to you to find out whether your insurance participates in this service. We require an EKG and blood work at the evaluation. Please do not wear any lotions or powders for the fact that it could interfere with these medical services. You are not required to complete the blood work outside of the office. Everything that is completed in the office that pertains to the assistance of your weight loss is included in the price of services.

3 Patient Information Name: Social Security #: Age: Date of Birth: Address: City: State: _ Zip: Home Phone: ( ) Cell Phone: ( ) Please Circle: Male Female Occupation: _ Emergency Contact Information: Emergency Contact Phone: ( )_ Please List Any Current Health Concerns/ Conditions/ Symptoms: Please List Any Surgeries You Have Had:

4 Medications Currently Taking: Please List Any Drug Allergies: Have You Been Seen By A Medical Doctor In The Last Six Months? Name Of Primary Care Physician: Female Patients Only Do You Have Regular Periods? Have You Had Any Pregnancies? Is There Any Way You Could Be Pregnant?

5 Weight History Current Weight: Goal Weight: _ Height: Do You Smoke? If Yes, How Much? Do You Drink? If Yes, How Much? What Do You Believe Is The Source Of Your Weight Gain? (ie. Family History, Eating Habits, Pregnancy) Do You Have Any Food Allergies, Dislikes, Or Cravings? Have You Attempted Any Other Diets? If So, How Many? Why Didn t They Work Out For You? What Is Your Level Of Activity? Please Circle One: (0 = Very Low and 5 = Very High)

6 What Dietary Problems Apply To You? Please Check All That Apply. Skipping Meals Carbohydrate Cravings Large Portion Size Too Much Alcohol Frequent Snacking Eating Fatty Foods Eating Out Frequently Stress Eating Eating Late Binging On Food What Is Your Motivation For Wanting To Lose The Weight? Please Check All That Apply. Unhappy With Appearance Need More Energy More Mobility Attending A Wedding/ Reunion Better Performance Gain Confidence Reduce Medications Upcoming Event/Vacation Clothes Do Not Fit Anymore Improve Health To Drop A Size To Improve Livelihood Other ( Please Describe)

7 Authorization of Medical Treatment I hereby authorize Dr. Brian C. Kroll, D.O. and his associates at First Choice Family Medical Center to provide any medical treatment, which in their judgment is deemed proper and medically necessary. Patient s Printed Name Patient s Date of Birth Patient, Guardian or Legal Representative s Signature Today s Date

8 Consent To Release Protected Health Information For Treatment, Payment, and Healthcare Operations I hereby authorize Dr. Brian C. Kroll, D.O. and his associates at First Choice Family Medical Center to release my personal protected information for treatment of my health condition to any other physician or healthcare provider directly or indirectly involved in my care and treatment. Direct involvement example: a specialist or hospital to which Dr. Brian C. Kroll has referred me to. Indirect involvement example: a laboratory, physicians of radiology or pathology. I understand that Mental Health, Substance Abuse, and HIV/AIDS related treatment will require an additional release of information authorization each time the information is requested for treatment purposes, except in any emergency treatment situation, as this is Dr. Brian C. Kroll s office policy. I understand that First Choice Family Medical Center will make all attempts to protect my confidential protected health information at all times. When the practice discloses my information it will be to authorized personnel and at the minimal amount of necessary information to accomplish the purpose. Some possible purposes include the purpose of billing, payment, and collections. I understand that I can request at any time an accounting of disclosure (release of information) for treatment, payment, or healthcare operations. I hereby consent and authorize First Choice Family Medical Center to use my protected health information for healthcare operations, such as quality assurance, improvement, healthcare oversight, and as required by federal and state laws. I understand that I may revoke this consent in writing at any time. Patient s Printed Name Patient s Date of Birth Patient, Guardian or Legal Representative s Signature Today s Date

9 Acknowledgment of Receipt of Notice of Privacy Practices I acknowledge that I have received a copy of First Choice Family Medical Center s Notice of Privacy Practices. I may request an additional copy from the practice at any time. I understand that I may ask if any changes have been made in the Notice of Privacy Practices, either each time I visit the office or by phone, and if there have been changes made to this Notice of Privacy Practices, the practice will provide me with a copy upon my request. Patient, Guardian or Legal Representative s Printed Name Relationship to Patient Patient s Printed Name Patient s Date of Birth To Staff Member: Upon request, a copy of this signed acknowledgment shall be supplied to the patient, guardian or legal representative. Staff Witness/Title Today s Date and Time Once processed, this form MUST be placed in the patient s medical records. Be sure to photocopy any ID s supplied by the patient, guardian, or legal representative. In the event of the patient s refusal to sign this acknowledgment, explain here and notify the provider. Initial, Date, and Time: Staff Witness/Title Today s Date and Time

10 Patient s Rights and Responsibilities Statement Statement of Patient s Rights Patients have the right to be treated with dignity and respect. Patients have the right to fair treatment, regardless of their race, religion, gender, ethnicity, age, disability, or source of payment. Patients have the right to have their treatment and other member information kept private. Only by law may records be released without patient permission. Patients have the right to easily access care in a timely fashion. Patients have the right to know all about their medical choices. This is regardless of cost or coverage by the patient s benefit plan. Patients have the right to share in the development of their plan of care. Patients have the right to information in a language they can understand. Patients have the right to have a clear explanation of their condition. Patients have the right to a clear explanation of their treatment options. Patients have the right to get information about their insurance carrier s services and role in the treatment process. Patients have the right to provide input on their insurance carrier s policies and services. Patients have the right to know the clinical guidelines used in providing and managing their care. Patients have the right to information about provider work history and training. Patients have the right to know about advocacy and community group and prevention services. Patients have a right to freely file a complaint, grievance, or appeal and to learn how to do so. Patients have the right to know about laws that relate to their rights and responsibilities. Patients have the right to know of their rights and responsibilities in the treatment process. Patient, Guardian or Legal Representative Signature Today s Date and Time

11 Patient s Rights and Responsibilities Statement Statement of Patient s Responsibilities Patients have the responsibility to treat those giving them care with dignity and respect. Patients have the responsibility to give providers information they need. This is so providers can deliver the best possible care. Patients have the responsibility to ask their providers questions about their care. This is so they can understand their role in that care. Patients have the responsibility to follow treatment plans for their care. The plan of care is to be agreed upon by the patient and provider. Patients have the responsibility to follow their agreed upon medication plan. Patients have the responsibility to tell their provider about medication changes, including medications given to them by others. Patients have the responsibility to keep their appointments. Patients should call their provider as soon as possible if they need to cancel visits. Patients have the responsibility to let their provider know when the treatment plan no longer works for them. Patients have the responsibility to let their provider know about problems with paying fees. Patients have the responsibility to not take actions that could harm others. Patients have the responsibility to report abuse. Patients have the responsibility to report fraud. Patients have the responsibility to openly report concerns about quality of care. Patient, Guardian or Legal Representative Signature _ Today s Date and Time

12 Weight Loss Bill of Rights WARNING: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 ½ pounds to 2 pounds per week or weight loss of more than 1% of body weight per week after the second week of participation in a weight loss program. Consult your personal physician before starting any weight loss program. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long term weight loss. Qualifications of this provider are available upon request. You Have a Right To Ask questions about the potential health risks of this program and its nutritional content, physiological support, and educational components. Receive an itemized statement of the actual or estimated price of the weight loss program, including extra products, services, supplements, examinations, and laboratory tests. Know the actual or estimated duration of the program. Know the name, address, and qualifications of the dietitian or nutritionist who has reviewed and approved weight loss program according to s (1)(j), Florida Statutes. Patient, Guardian or Legal Representative s Signature Today s Date

13 Controlled Substance Agreement Controlled substance medications are very useful but have a high potential for misuse and are, therefore, closely controlled by local, state and federal governments. Because my physician is prescribing controlled substance medications, I agree to the following conditions: 1. I am responsible for the controlled substance medication supplied to me. Refills will not be made if they RUN OUT EARLY, LOSE A PRESCRIPTION, or if MEDICATION HAS BEEN STOLEN. I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. I understand that I MUST be seen in the office every week in order to continue receiving prescription refills. Initials 2. I understand that the main treatment goal is to promote weight loss and improve my health. In consideration of this goal, and the fact that I am being given a potent medication to help me reach this goal, I agree to help myself by following better health habits such as exercising, weight control and the avoidance of the use of tobacco and alcohol. I must also comply with the treatment plan as prescribed by my physician. Initials 3. Female patient: I am aware that it is my responsibility to immediately inform the treating physician if I plan to or become pregnant. Pain management treatment including medications and injection therapy could result in harmful effects to the developing fetus. Initials 4. I understand that ID and signature are required for me or another individual to pick up prescriptions. Initials 5. I understand that if I violate any of the above conditions, my prescription for controlled substance medications may be terminated immediately. If the violation involves obtaining controlled substance medications from another individual, or the use of non-prescribed illicit (illegal) drugs, I may also be reported to all of my physicians, medical facilities, and appropriate authorities. Any repeated violation listed above could lead to being discharged from the Orion Rapid Weight Loss Program. Initials

14 Acknowledgment of Agreement I,, declare that I have received, read, understand, and agree with the Controlled Substance Agreement. The same will be explained to me by the physician as well. In addition, I fully understand the consequences of violating this agreement. Patient, Guardian or Legal Representative s Signature Today s Date Staff Witness/Title Today s Date and Time *This form is a necessary response due to changing regulations and enforcements. There is no assumption that you will purposely misuse your medications.

15 Waiver of Liability I have elected to seek medical treatment at the Orion Rapid Weight Loss Program, at the office of Dr. Brian C. Kroll, D.O. and understand that I am personally responsible for the payment of all services rendered. Any money owed will be paid in full on or before your next visit. Patient, Guardian or Legal Representative s Signature Today s Date

16 How Did You Hear About Us? Please let us know how you heard about our weight loss program, whether it was through one of our sources of advertisement or by word of mouth. Orion Rapid Weight Loss Program provides a rewards plan for those that refer patients to our office. For every patient that is referred to us and begins the program, we provide one free week. Please Circle: Commercial Billboard Newspaper/Newsletter Internet Friend Name:

17 Authorization to Utilize/Release Weight Loss Photographs I,, authorize Orion Rapid Weight Loss and Dr. Brian Kroll to use photographs I have provided for promotional, advertising, and marketing purposes as they see fit and appropriate. These marketing uses may include, but are not limited to: in-office bulletin board(s), website, flyers, television, commercials, etc. I release all copyrights to Orion Rapid Weight Loss for the aforementioned purposes. I understand that my photographs will not be sold or used for means other than marketing and advertising for Orion Rapid Weight loss exclusively. Patient, Guardian or Legal Representative s Signature Today s Date

Pediatric Patient History

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

More information

Medical History Form

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

More information

Signature (Patient or Legal Guardian): Date:

Signature (Patient or Legal Guardian): Date: X-Ray Patient Information: [ ] Male [ ] Female Patient Name: Date of Birth: / / SS#: Mailing Address: City: State: Zip: Phone # s: (Home) (Work) (Cell) Referring Physician: Phone #: /Fax#: Additional Physician:

More information

NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE

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

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care

More information

PATIENT INFORMATION Please Print

PATIENT INFORMATION Please Print PATIENT INFORMATION Please Print DATE Patient s Last Name First Name Middle Name Suffix Gender: q Male q Female Social Security Number of Birth Race Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred

More information

12086 Ft. Caroline Road, Suite #401, Jacksonville, FL Phone: (904) Fax: (904) Patient Full Legal Name Date

12086 Ft. Caroline Road, Suite #401, Jacksonville, FL Phone: (904) Fax: (904) Patient Full Legal Name Date 12086 Ft. Caroline Road, Suite #401, Jacksonville, FL 32225 Phone: (904) 565-1271 Fax: (904) 645-7325 James A. Joyner, IV, MD, Kia M. Mitchell, MD, Thanh Nguyen, MD Dewey Lee, III, PA, Linda Rowan-Vander

More information

Fulcrum Orthopaedics Patient Registration Packet

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

More information

Amarillo Endoscopy Center Srinivas Pathapati, MD., PA 6833 Plum Creek Drive Amarillo, TX (806)

Amarillo Endoscopy Center Srinivas Pathapati, MD., PA 6833 Plum Creek Drive Amarillo, TX (806) Today s Date: / / PATIENT INFORMATION Patient s Last Name First Middle Mr. Miss Mrs. Ms. Marital Status (Circle one) Single / Mar / Div / Sep / Widow Legal Name (If applicable) Maiden Name Birth Date Age

More information

Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE

Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE Date: / / Name: Date of Birth: / / Age: Sex: M F ETHNIC ORIGIN: White Hispanic Haitian African American Other: PRIMARY LANGUAGE: English Spanish

More information

Pain Management Specialists of Southfield Michigan. Michigan Orthopaedic Institute. Thank you for choosing us for your Pain Management Services.

Pain Management Specialists of Southfield Michigan. Michigan Orthopaedic Institute. Thank you for choosing us for your Pain Management Services. Cain E. Dimon, M.D. Craig S. McCardell, M.D. Helen Puffenberger, PA C Pain Management Specialists of Southfield Michigan A Division of: South Oakland Anesthesia Associates Providing Services at Michigan

More information

NEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone. Address: Driver s License #:

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

More information

Outpatient Wellness Clinic

Outpatient Wellness Clinic Outpatient Wellness Clinic Patient Name: Date of Birth: Address: Phone: Email: Emergency Contact: Relationship: Phone: What is the reason for the appointment? Who were you referred by? (Physician, agency/

More information

WELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice.

WELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice. WELCOME Those of us at Crossroads Counseling want to thank you for choosing to work with us and we want to make your time with us as productive as possible. In order to expedite the intake process, please

More information

Rotary District 5180/5190 RYLA REGISTRATION FORM 2018

Rotary District 5180/5190 RYLA REGISTRATION FORM 2018 Rotary District 5180/5190 RYLA REGISTRATION FORM 2018 ROTARY CLUB OF: ROTARY CLUB CONTACT: This form must be completed in full and signed by the student as well as a parent or legal guardian in multiple

More information

NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:

NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone: NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:

More information

SPRING BRANCH COMMUNITY HEALTH CENTER

SPRING BRANCH COMMUNITY HEALTH CENTER Hillendahl Clinic 1615 Hillendahl Blvd., Suite 100 Houston, TX 77055 (713) 462-6565 Pitner Clinic 8575 Pitner Road Houston, TX 77080 (713) 462-6545 Mon, Wed, Fri: 8am-5pm Tues & Thurs: 8am-8pm 1 st & 3

More information

Welcome to the Office of Dr. Sam Van Kirk!

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,

More information

Patient Registration Form

Patient Registration Form Date: Padma Sripada MD, Columbia Internal Medicine 2500 Pond View, Suite 202 Castleton on Hudson, NY 12033 Phone: 518-391-2889 Patient Registration Form First Name Middle Last Name... Sex: M F Date of

More information

PATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments.

PATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments. PATIENT NOTICE Our goal at is to provide quality medical care. Because of our concern for your health and well-being, there are certain types of medications we may not be able to prescribe to you. Examples

More information

Fulcrum Orthopaedics Patient Registration Packet

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

More information

SPOUSE/GUARDIAN (If patient is married, give spouse information. If patient is a child, give parent information.)

SPOUSE/GUARDIAN (If patient is married, give spouse information. If patient is a child, give parent information.) Please Fill Out Completely: St. Mary s Women s Center 1000 Cowles Clinic Way, Suite D-300 Greensboro, GA 30642 762-243-3860 phone 762-243-3879 fax Patient s Last Name First Name MI Social Security Number

More information

HEALTH HISTORY QUESTIONNAIRE

HEALTH HISTORY QUESTIONNAIRE Patient Name: of Birth: HEALTH HISTORY QUESTIONNAIRE Primary Care Physician: Other physicians you currently see: Emergency Phone #: Contact Person/Relationship: Reason for the Visit: Please list your medications

More information

1.2 ADULT CLIENT INTAKE FORM: Client Information

1.2 ADULT CLIENT INTAKE FORM: Client Information 1.2 ADULT CLIENT INTAKE FORM: Client Information FOR OFFICIAL USE ONLY: Client Number Effective Insurance No OH No CLIENT INFORMATION Client name of significant other CHILDREN INFORMATION of birth of birth

More information

APPOINTMENT INFORMATION SHEET

APPOINTMENT INFORMATION SHEET APPOINTMENT INFORMATION SHEET All appointments for new patients will require a one-time, refundable deposit of $50.00 to secure your appointment. You may use cash, check or credit card. The check or credit

More information

Please Print Affiliation (school, company name, etc): Mailing Address: City: Postal Code: Home Phone: Cell Phone: Work: Date of Birth (DD/MM/YY):

Please Print Affiliation (school, company name, etc): Mailing Address: City: Postal Code: Home Phone: Cell Phone: Work: Date of Birth (DD/MM/YY): Name: Volunteer Application Thank you for your interest in volunteering with Habitat for Humanity Wellington Dufferin Guelph. The information you provide will help us to place you in a volunteer position

More information

Initials of State and Out of State DL # Complete as Applicable

Initials of State and Out of State DL # Complete as Applicable Bridgeway Center Inc. Community & Court Education Services Enrollment Form Have you ever attended any classes at Bridgeway Center, Inc.? Yes No Today s Date First Name Middle Name Last Name / / Address

More information

Counseling Center of Montgomery County

Counseling Center of Montgomery County Counseling Center of Montgomery County 212 Conroe Drive (936) 760-1880 Office Conroe, TX 77301 (936) 760-2915 Office CCMC@CounselingCenterMoCo.com (936) 760-9101 Fax CHILD/ADOLESCENT PSYCHOSOCIAL HISTORY

More information

PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # HOME PHONE # CELL PHONE # WORK PHONE #

PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # HOME PHONE # CELL PHONE # WORK PHONE # PATIENT INFORMATION PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # STREET ADDRESS CITY, STATE, ZIP HOME PHONE # CELL PHONE # WORK PHONE # Emergency Contact & relationship: Phone #: Pharmacies local and

More information

Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology

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

More information

PATIENT INFORMATION. In Case of Emergency Notification

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

More information

Epic Pain Management & Anesthesia Consultants, LLC PO Box 1779, Fort Lee, NJ REGISTRATION FORM

Epic Pain Management & Anesthesia Consultants, LLC PO Box 1779, Fort Lee, NJ REGISTRATION FORM REGISTRATION FORM Name (First) (Middle) (Last) M F Social Security of Birth Age Marital Status Single Married Civil Union Widow/ Widower Home Address City State Zip Code Work Address (Cell) (Home) (Work)

More information

Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL

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

More information

CATARACT AND LASER CENTER, LLC

CATARACT AND LASER CENTER, LLC CATARACT AND LASER CENTER, LLC Patient Information Date: Patient Name: M F Address: Street City State Zip Home Phone: Work Phone: Cell Phone: E-Mail : Referred by: Medical Doctor: Who is your regular eye

More information

Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801

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:

More information

Medications List. Allergies. Drug Name Dosage Directions Reason Taking

Medications List. Allergies. Drug Name Dosage Directions Reason Taking Patient Name: DOB: Medications List Allergies Please list any medications you are currently taking Drug Name Dosage Directions Reason Taking Preferred Pharmacy: Date: Location/Number: New Patient Background

More information

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.

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,

More information

Welcome to Optimum Chiropractic & Wellness Center To The NEW PATIENT Outline of Procedures for Care And Consent to Initiate Care

Welcome to Optimum Chiropractic & Wellness Center To The NEW PATIENT Outline of Procedures for Care And Consent to Initiate Care Welcome to Optimum Chiropractic & Wellness Center To The NEW PATIENT Outline of Procedures for Care And Consent to Initiate Care We are dedicated to providing the highest quality chiropractic health care

More information

DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Missouri Revised Statutes to )

DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Missouri Revised Statutes to ) DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Missouri Revised Statutes 404.800 to 404.865) THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS: Except

More information

James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL

James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL 34471 352-867-0444 Dear Patients: Welcome to our orthopaedic office. We appreciate your confidence and will take great

More information

PATIENT INFORMATION Indiana Plastic Surgery Center, PC

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

More information

Re-Vita -Life. Sub-dermal Bio-identical Pellets

Re-Vita -Life. Sub-dermal Bio-identical Pellets Re-Vita -Life Sub-dermal Bio-identical Pellets Welcome and thank you for inquiring about Re-Vita-Life Bio-identical hormone replacement therapy. We have included a new patient information packet which

More information

Camp TOV Medical Form

Camp TOV Medical Form Mail: Fax: Please send these forms to us by either: Jewish United Fund/Jewish Federation of Metropolitan Chicago Attn: Camp TOV 30 South Wells Street, Room 5034 Chicago, IL 60606 Attn: Camp TOV 312-444-2086

More information

YOGA HEALTH HISTORY. First Middle Last. Address: Street Apt City State Zip. Home Phone: Cell Phone: address:

YOGA HEALTH HISTORY. First Middle Last. Address: Street Apt City State Zip. Home Phone: Cell Phone:  address: YOGA HEALTH HISTORY Name: First Middle Last Address: Street Apt City State Zip Home Phone: Cell Phone: Email address: Date of Birth: Gender: Marital Status: Employment: Full-Time Part-Time Student Retired

More information

ICM Food & Clothing Bank Volunteer Application

ICM Food & Clothing Bank Volunteer Application Please print legibly. Date: / _/ ICM Food & Clothing Bank Volunteer Application Name: Email: Tel: ( ) Cell: ( ) Address: City: State: Zip: Emergency Contact Tel: 1. How did you hear about ICM? (i.e., school,

More information

SAISD Volunteer Information Packet

SAISD Volunteer Information Packet SAISD Volunteer Information Packet Thank you for choosing to volunteer in the San Antonio Independent School District. We hope that the time that you spend volunteering at SAISD is both fun and rewarding.

More information

Pediatric Psychology

Pediatric Psychology Pediatric Psychology Welcome to Pediatric Psychology at CHOC Children's. Please read this information carefully and write down any questions that you might have, so that we can discuss them. PSYCHOLOGICAL

More information

Welcome to LifeWorks NW.

Welcome to LifeWorks NW. Welcome to LifeWorks NW. Everyone needs help at times, and we are glad to be here to provide support for you. We would like your time with us to be the best possible. Asking for help with an addiction

More information

Dauphin County Harrisburg Aurora Center Orientation Manual

Dauphin County Harrisburg Aurora Center Orientation Manual A AURORA SOCIAL REHABILITATION SERVICES Our Vision Statement Our Vision is to ensure our consumers have a safe and secure place to participate in educational, recreational, and social activity that is

More information

Acknowledgement of Notice of Privacy Practices

Acknowledgement of Notice of Privacy Practices OMEGA HEIGHTS FAMILY MEDICINE CLINIC Acknowledgement of Notice of Privacy Practices I have been presented with a copy of the Notice of Privacy Practices for Omega Heights Family Medicine Clinic, detailing

More information

Complete Senior Care Enrollment Agreement

Complete Senior Care Enrollment Agreement Complete Senior Care Enrollment Agreement I have received the Enrollment Handbook and a copy of the Provider Network and have had the opportunity to ask questions. Name: Address: (First) (Middle) (Last)

More information

Parental Consent For Minors to Receive Services

Parental Consent For Minors to Receive Services Parental Consent For Minors to Receive Services Welcome to the University of San Diego s Wellness Area! We appreciate your coming our way, and look forward to working with you. The following provides important

More information

PATIENT REGISTRATION FORM

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#:

More information

Developmental Pediatrics of Central Jersey

Developmental Pediatrics of Central Jersey PATIENT INFORMATION: CLIENT INFORMATION Date: Name: (Last) (First) (M.I.) Birthdate: Sex: Race: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email Address: Regarding the office staff or physician

More information

Kent State University Health Services. Medical History Form

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

More information

C OMMUNITY, C OUNSELING, AND C ORRECTIONAL S ERVICES, I NC. WATCH West PROGRAM Visitor Application

C OMMUNITY, C OUNSELING, AND C ORRECTIONAL S ERVICES, I NC. WATCH West PROGRAM Visitor Application C OMMUNITY, C OUNSELING, AND C ORRECTIONAL S ERVICES, I NC. WATCH West PROGRAM Visitor Application Please Print Any incorrect, incomplete, false or misleading information on this application will void

More information

Colorado Therapeutic Riding Center Mineral Road, Longmont, CO (303) FAX (303)

Colorado Therapeutic Riding Center Mineral Road, Longmont, CO (303) FAX (303) Colorado Therapeutic Riding Center 11968 Mineral Road, Longmont, CO 80504 (303) 652-9131 FAX (303) 652-2072 Dear Prospective Intern: Thank you for your interest in interning at the Colorado Therapeutic

More information

Welcome to Baptist Medical Group - Westside. Please read the below information carefully to prepare for your upcoming appointment.

Welcome to Baptist Medical Group - Westside. Please read the below information carefully to prepare for your upcoming appointment. BAPTISTMEDICALGROUP.ORG Westside Welcome to - Westside Please read the below information carefully to prepare for your upcoming appointment. Please arrive 15 minutes prior to your regularly scheduled appointment

More information

Provider Certification Standards Adult Day Care

Provider Certification Standards Adult Day Care Provider Certification Standards Adult Day Care December 2015 1 Definitions: Activities of Daily Living (ADL s)- Includes but is not limited to the following personal care activities: bathing, dressing,

More information

Kermit M. Rudolf Fitness Center New Membership Application Packet

Kermit M. Rudolf Fitness Center New Membership Application Packet Kermit M. Rudolf Fitness Center New Membership Application Packet Dear Prospective Spouse/Registered Domestic Partner/Family Member: Thank you, for your interest in the Kermit M. Rudolf Fitness Center

More information

East Baton Rouge Parish Junior Deputy

East Baton Rouge Parish Junior Deputy East Baton Rouge Parish Junior Deputy 2018 Application Packet Sheriff Sid J. Gautreaux, III Captain Randy M. Aguillard Program Director raguillard@ebrso.org Junior Deputy Membership Rules All members of

More information

STATE OFFICER CANDIDATE APPLICATION (Please Print)

STATE OFFICER CANDIDATE APPLICATION (Please Print) DEADLINE: January 31, 2017 Submit by the deadline for DECA State Conference registration materials. NO FAXES WILL BE ACCEPTED ALABAMA DECA HIGH SCHOOL DIVISION STATE OFFICER CANDIDATE APPLICATION (Please

More information

Alzheimer s Arkansas is pleased to provide you with information about the Family

Alzheimer s Arkansas is pleased to provide you with information about the Family PLEASE READ ALL INFORMATION INCLUDED IN THIS GRANT APPLICATION Dear Caregiver: Alzheimer s Arkansas is pleased to provide you with information about the 2016-2017 Family Caregiver Support Program. Funding

More information

HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.

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:

More information

Welcome to the Southeastern Urology Associates meridianemr Patient Portal

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

More information

Reminders for you as you come in for your first appointment

Reminders for you as you come in for your first appointment Reminders for you as you come in for your first appointment * Please complete this paperwork and bring it to your first appointment If you are unable to complete this paperwork prior to your appointment,

More information

MIND MATTERS PSYCHIATRYMD PATIENT INTAKE FORMS LONG PRAIRIE ROAD SUITE 100 FLOWER MOUND, TX 75022

MIND MATTERS PSYCHIATRYMD PATIENT INTAKE FORMS LONG PRAIRIE ROAD SUITE 100 FLOWER MOUND, TX 75022 MIND MATTERS PSYCHIATRYMD PATIENT INTAKE FORMS 2017 2620 LONG PRAIRIE ROAD SUITE 100 FLOWER MOUND, TX 75022 Whose # is this? Whose # is this? 2 2 3 4 fa 5 6 X 7 8 Mind Matters PsychiatryMD Patient Responsibilities

More information

INTAKE SURVEY FOR INITIAL INTERVIEW. Name Date Age Birth date Address: Phone numbers: Emergency Contacts & Relationship:

INTAKE SURVEY FOR INITIAL INTERVIEW. Name Date Age Birth date Address: Phone numbers:   Emergency Contacts & Relationship: 1 INTAKE SURVEY FOR INITIAL INTERVIEW Name Date Age Birth date Address: Phone numbers: Email: Emergency Contacts & Relationship: Phone numbers for EmergencyContacts: Employment or school grade Why are

More information

Toolbox Talks. Access

Toolbox Talks. Access Access The detail of what the Healthcare Charter says in relation to what service users can expect and what they can do to help in relation to this theme is outlined overleaf. 1. How do you ensure that

More information

District Handbook for Club Presidents and RYLA Chair Persons Rotary District Dave Stuckey, Chair

District Handbook for Club Presidents and RYLA Chair Persons Rotary District Dave Stuckey, Chair 2018 District 7710 Handbook for Club Presidents and RYLA Chair Persons Rotary District 7710 Dave Stuckey, Chair 1 Table of Contents What is RYLA?. 3 Application Procedures 4 Selection Criteria. 5 What

More information

Jodi Bremer-Landau, PhD Licensed Psychologist

Jodi Bremer-Landau, PhD Licensed Psychologist WELCOME TO MY PRACTICE Welcome! I recognize that it takes a lot of courage to seek services and I truly appreciate your interest in working together. I look forward to making progress with you as we journey

More information

Return Completed Application To: ARISE & Ski, 635 James Street, Syracuse, NY 13203

Return Completed Application To: ARISE & Ski, 635 James Street, Syracuse, NY 13203 ARISE & Ski Volunteer Application We consider applicants for all positions without regard to race, religion, creed, gender, age, disability, marital or veteran status, sexual orientation or any other legally

More information

Ideal Physician Weight Loss Bariatric & Cosmetic Surgery NEW PATIENT INFORMATION

Ideal Physician Weight Loss Bariatric & Cosmetic Surgery NEW PATIENT INFORMATION Ideal Physician Weight Loss Bariatric & Cosmetic Surgery NEW PATIENT INFORMATION Legal Name* Last: First: M.I. Preferred Name: Date of Birth: Marital Status: Legal Sex (Please Check one)* M F Pronouns:_

More information

www.thelmmfund.org info.thelmmfund@gmail.com SCHOLARSHIP APPLICATION FORM To apply for a scholarship from The Lisa Michelle Memorial Fund, please fill out the application below and submit all required

More information

MINOR Volunteer Application

MINOR Volunteer Application MINOR Volunteer Application (15 years and younger) Parent/Guardian/Legal Custodian Permission for Minor to participate in BPHI Volunteer Program and Consent for Emergency Medical treatment. Broward County

More information

Home & Community Based Services Waiver Member Handbook

Home & Community Based Services Waiver Member Handbook Home & Community Based Services Waiver Member Handbook For Members Enrolled in the MyCare Ohio Home and Community Based Services Waiver H2531_160714_124129 Approved 1 WELCOME Welcome! This handbook was

More information

Julie Gussenhoven, OD 3416 Bechelli Lane Redding, CA 96002

Julie Gussenhoven, OD 3416 Bechelli Lane Redding, CA 96002 Julie Gussenhoven, OD OCULAR AND MEDICAL HISTORY QUESTIONNAIRE Name: M F Date: Date of Birth: Home Phone: Social Security #: Cell Phone: Address: Work Phone: City: Zip: Email: Please complete all personal

More information

Patient Guide. Comfortable Place, Exceptional Care STATION. Outpatient Surgical Procedures. Surgical Center

Patient Guide. Comfortable Place, Exceptional Care STATION. Outpatient Surgical Procedures. Surgical Center Patient Guide Outpatient Surgical Procedures Comfortable Place, Exceptional Care TAYLOR STATION Surgical Center Welcome Thank you for selecting Taylor Station Surgical Center for your surgical procedure.

More information

The process has been designed to be user friendly and involves a few simple steps.

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

More information

PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES

PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES Helping People Perform Their Best PRIVACY, RIGHTS AND RESPONSIBILITIES NOTICE PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES Request Additional Information or to Report a Problem If you have questions

More information

Member Handbook. HealthChoices Allegheny County

Member Handbook. HealthChoices Allegheny County Member Handbook HealthChoices Allegheny County Contents Welcome to Community Care! 3 About Community Care 6 Behavioral Health Services for HealthChoices Members 9 Getting Help 11 Your Rights and Responsibilities

More information

All clubs will receive a confirmation including directions, waiver forms and other pertinent information upon receipt of registration.

All clubs will receive a confirmation  including directions, waiver forms and other pertinent information upon receipt of registration. IDENTITY YMCA of Greater Fort Wayne Teen Service Day WHO: Teens in the Fort Wayne area. Must be in grades 6-12. WHERE: The YMCA of Greater Fort Wayne Central Branch WHEN: December 28 th, 2017 9:00am-9:00pm

More information

We welcome you as a patient

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

More information

1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY

1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY 2016-17 South Carolina 4-H Membership and Event Permission Form for Youth (Updated 08.01.16) ALL elements of this form must be completed by youth participating in clubs, field trips, events requiring group

More information

Call Us at or Your appointment has been scheduled for at the Minnesota Men s Health Center, with Dr. Schow.

Call Us at or Your appointment has been scheduled for at the Minnesota Men s Health Center, with Dr. Schow. Call Us at 651-730-0775 or 888-685-3700 Date Dear Your appointment has been scheduled for at the Minnesota Men s Health Center, with Dr. Schow. Enclosed is the surgery scheduling agreement, health status

More information

REGISTRATION DEADLINE: Feb. 9, 2018

REGISTRATION DEADLINE: Feb. 9, 2018 Richland High School Feb. 17, 2018 REGISTRATION DEADLINE: Feb. 9, 2018 Student Name: Home Address: City: State: Zip: Phone: Email: Date of Birth: Gender: Male Female T-shirt size: Ethnicity (optional):

More information

Patient Name: Date of Birth:

Patient Name: Date of Birth: : Patient Agreement Welcome to Community Psychiatry Community Psychiatry s dedicated providers and staff are committed to ensuring that each and every patient receives the highest quality psychiatry services

More information

MICHELE S. GREEN, M.D.

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

More information

Consumer Rights and Responsibilities. Consumers have the RIGHT to receive accurate information Consumers have the RIGHT to be treated with Respect

Consumer Rights and Responsibilities. Consumers have the RIGHT to receive accurate information Consumers have the RIGHT to be treated with Respect Consumer Rights and Responsibilities. Consumer s have certain rights guaranteed by the Constitution of the United States, including the first ten amendments which are known as the Bill of Rights, the Constitution

More information

Texas Higher Education oordinating oard Office of General ounsel P.O. ox 12788!ustin, TX

Texas Higher Education oordinating oard Office of General ounsel P.O. ox 12788!ustin, TX Student Information Name: Last First Middle Initial Address: City State Zip Phone: Date of Birth: Program of Study Email: at the Institution: Check the applicable box which describes your status with the

More information

Registration Form. School Name: Start Date: Grade:

Registration Form. School Name: Start Date: Grade: Registration Form Program Type: Afterschool Care Before Care School Name: Start Date: Grade: Child's Full Name: Address: City: Zip Code: Sex: Female Male Race: White Hispanic Black Other Hair Color: Eye

More information

I, (print your name) request that my physician release medical information to Project Angel Food / / DOB (Date of birth)

I, (print your name) request that my physician release medical information to Project Angel Food / / DOB (Date of birth) Eligibility and Consent Form Project Angel Food is a non profit organization that feeds the sick as they battle critical illness. We home deliver nutritious meals, free of charge, to homes within Los Angeles

More information

Your Rights and Responsibilities as a Patient at Sparrow Hospital

Your Rights and Responsibilities as a Patient at Sparrow Hospital Your Rights and Responsibilities as a Patient at Sparrow Hospital Sparrow s mission is to improve the health of the people in our communities by providing quality, compassionate care to every person, every

More information

Handbook for Club Presidents and RYLA Chair Persons Rotary District Dave Stuckey, Chair

Handbook for Club Presidents and RYLA Chair Persons Rotary District Dave Stuckey, Chair 2017 Handbook for Club Presidents and RYLA Chair Persons Rotary District 7710 Dave Stuckey, Chair 1 Table of Contents What is RYLA?... 3 Application Procedures...4 Selection Criteria... 5 Info to share

More information

Langston University Returning Athlete Screening Form

Langston University Returning Athlete Screening Form Langston University Returning Athlete Screening Form Name: Address: Social Security #: : Phone: Sport: DOB: M / D / Y 1. Have you had any injury since your last athletic screening here? Yes: No: If yes,

More information

MEMBER HANDBOOK. Health Net HMO for Raytheon members

MEMBER HANDBOOK. Health Net HMO for Raytheon members MEMBER HANDBOOK Health Net HMO for Raytheon members A practical guide to your plan This member handbook contains the key benefit information for Raytheon employees. Refer to your Evidence of Coverage booklet

More information

Helping others grow and excel through their interaction with horses 3498 Barclay Messerly Road Southington, Ohio 44470

Helping others grow and excel through their interaction with horses 3498 Barclay Messerly Road Southington, Ohio 44470 Dear Prospective Volunteer: Helping others grow and excel through their interaction with horses 3498 Barclay Messerly Road Southington, Ohio 44470 Ph. (330) 889-0036 www.thecamelotcenter.org ==============================================================

More information

Patient-Triage Assessment Form

Patient-Triage Assessment Form Patient-Triage Assessment Form Date: / / 20 U# _ Name: Date of Birth: / / 19 In order to provide you with outstanding medical care-please explain why you are here (list symptoms). In the past 48-72 hours,

More information

Patient Appointment Agreement

Patient Appointment Agreement Patient Appointment Agreement Welcome and thank you for choosing the East Carolina University School of Dental Medicine for your oral health care needs. We are committed to providing you with the best

More information

Sample Notice of Privacy Practices 2 of 6 cda.org/practicesupport

Sample Notice of Privacy Practices 2 of 6 cda.org/practicesupport Sample Notice of Privacy Practices 2 of 6 cda.org/practicesupport RUSSELL L. CURETON D.D.S. Notice of Privacy Practices This Notice describes how your health information may be used and disclosed and how

More information