PARADISE ARTHRITIS & RHEUMATOLOGY
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1 PARADISE ARTHRITIS & RHEUMATOLOGY Rheumatologists Paradise Arthritis & Rheumatology Dr Jennifer NG Level 4, Suite 5 Dr Jacklyn Chay 123 Nerang St, Southport 4215 Dr Sateesh Shankaranarayana Ph: Dr Jeff Tsai Fax: reception@panr.com.au Nurse Practitioners Ann Robinson Tammy Schmidt APPOINTMENT FOR: DATE and TIME: PLEASE NOTE OUR POLICY REGARDING APPOINTMENT CONFIRMATION/CANCELLATION There is a list of people waiting for URGENT new consultations so appointment time each day is a precious commodity. Please complete information and bring with you to your appointment. To avoid cancellation of your appointment you are responsible for confirming your appointment date and time a minimum of 24 hours in advance of your consultation. If you do not confirm your appointment 24 hours in advance and we are unable to contact you, your appointment may be automatically cancelled and another patient on the waiting list will be allocated your appointment and you will need to be rescheduled at Dr s discretion. Thank you for making an appointment. We are pleased to have you as a new patient and enclosed is some information to assist you with your visit to our practice. Practice Hours: Monday Friday 8.30am 5pm On the day of your appointment please bring your referral and any other information that may assist in your care.
2 Please NOTE we do not do worker s compensation claims. Consultation Fees: All consultation fees are Medicare rebatable. We can do the Medicare rebate if your details are registered with Medicare. We do not accept cheques or gap payments. If an injection is required for pain relief (at the Dr s discretion) the injections are at an extra charge. Fees are discounted for Aged Pensioners and Health Care card holders. Please note that our consultation is payable in full on the day of your appointment. At the time of making the appointment the fee structure will be explained to you. General information for your visit: Free underground parking is available at Pacific Private Clinic entry is via Cougal Street. Arrival: Please arrive at least 10 minutes before your appointment with your referral, pathology, Medicare, Health Care/Aged Pension cards for registration. In many instances your GP/Specialist may fax or your referral and pathology prior to your visit. (GP referrals are valid for 12 months, specialist referrals are valid for 3 months). Cancellations: There is an appointment wait list to see the Doctor s here at Paradise Arthritis & Rheumatology and there are many patients who would be very appreciative if they were contacted to have their appointment moved to an earlier time. Please give 48 hours notice of any cancellation. General: Thank you once again for making an appointment with us. We look forward to meeting you and we hope this information assists you. Should you have any questions, please do not hesitate to call Yours sincerely Maureen Hedges Practice Manager
3 Your personal details Your name DOB Address Telephone Sms Y or N (please circle) Do you allow us to send requested information via the listed above Y or N Gender Female/Male Current occupation Previous occupation if retired Medicare number ref Exp Private Health Fund Fund No Dva Pension No Exp Your General Practitioner Your next of Kin Name Telephone No Relationship Permission to contact Y or N (circle) (If unable to contact you or emergency) Medications list (or attach list) Allergies to any medications
4 Major illness or hospitalisations Year Hospital/city Please tick the following if you ever had; if you answer yes please write AGE or YEAR started Yes No Yes No High blood pressure Thyroid problems High cholesterol Miscarriages (female) Heart attack Back/spine problems Stroke/TIA Rheumatoid Arthritis Emphysema/bronchitis Osteoarthritis Asthma Fibromyalgia Stomach ulcer osteoporosis Bowel problems Broken bones after age 50 Kidney problems Depression Diabetes Severe allergies Blood clots Psoriasis Dry eyes/mouth Other autoimmune diseases Iritis/uveitis Gout Other Other Father Mother Brother(s) Sister(s) Son(s) Daughter(s) Your family medical history If Living Age Any major medical conditions Age of death If Deceased Cause(s) of death Rheumatoid arthritis Lupus/SLE Crohn s/ulcerative colitis Please tick yes if there is blood family history, if yes, give relationship Relationship Relationship Osteoporosis Ankylosing Spondylitis Psoriasis
5 Your social history Have you ever smoked? Y or N (circle) if yes approximate number per day? How many years have you smoked? If stopped, when How much alcohol do you drink a day? (N/A if you don t drink) Relationship status If married, health of spouse (circle) Good Poor If poor, give details Health of others at home (circle) Good Poor If poor, give details I have read and understood the privacy policy The details given above are true and correct as of this Date Signature
6 WE RESPECT YOUR PRIVACY We are committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Private Act 199 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy Principles and relevant State and Territory privacy legislation (referred to as privacy legislation). This Privacy Policy explains how we collect, use and disclose your personal information, how you may access that information and how you may seek the correction of any information. It also explains how you may make a complaint about a breach of privacy legislation. This Privacy Policy is current from 07/07/2015. From time to time we may make changes to our policy, processes and systems in relation to how we handle your personal information. We will update this Privacy Policy to reflect any changes. Those changes will be available on our website and in the practice. We collect information that is necessary and relevant to provide you with medical care and treatment, and manage our medical practice. This information may include your name, address, date of birth, gender, health information, family history, credit card and direct debit details and contact details. This information may be stored on our computer medical records system and/or in hand written medical records. Wherever practicable we will only collect information from you personally. However, we may also need to collect information from other sources such as treating specialists, radiologists, pathologists, hospitals and other health care providers. We collect information in various ways, such as over the phone or in writing, in person in your Paradise Arthritis and Rheumatology practice or over the internet if you transact with us online. This information may be collected by medical and non-medical staff. In emergency situations we may also need to collect information from your relatives or friends. We may be required by law to retain medical records for certain periods of time depending on your age at the time we provide services. We will treat your personal information as strictly private and confidential. We will only use or disclose it for purposes directly related to you care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment. For example, the disclosure of blood test results to your specialist or requests for x-rays. There are circumstances where we may be permitted or required by law to disclose your personal information to third parties. For example, to Medicare, Police, insurers, solicitors, government regulatory bodies, tribunals, courts of law, hospitals, or debt collection agents. We may also form time to time provide statistical data to third parties for research purposes. If you have any questions regarding the information we collect from you and hold in your medical records, please do not hesitate to ask us. We are acting in your interests at all times.
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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:
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
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
Spine Solutions By Donald Mackenzie, MD Relieving the pain Healing the spine Rejuvenating the person
Welcome to by Donald Mackenzie, M.D. Dear Friend, Thank you for choosing me as your spine surgeon. I will personally do everything possible to deserve your trust. I see this as the beginning of a great
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)
Pediatric New Patient Form
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DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group
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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:
Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:
SALT LAKE EYE ASSOCIATES, LLC (801) 281-2020 1025 E 3300 S, SLC, Utah * Patient Information Sheet First Name: Last Name: Middle Initial: Referred By Family Doctor EMAIL Street Address: City: State: Zip:
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
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,
Allergies Drug Food Environmental. Previous Surgeries & Hospitalizations (Please list date, reason, and hospital)
Allergies Drug Food Environmental Previous Surgeries & Hospitalizations (Please list date, reason, and hospital) Habits Do you ever use the following? If yes, how often? Tobacco Alcohol Recreational Drugs
Entrance Case History (Please write or print clearly)
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Lipo Laser Weight Loss Action Plan
7921 Tanner Williams Road, Ste B Mobile, AL 36608 Phone 251.607.0040 Fax 251.607.7202 Lipo Laser Weight Loss Action Plan 1. Your first appointment today will consist of a consultation with a doctor. This