Dr. Ian C. MacIntyre
|
|
|
- Sherilyn Wright
- 6 years ago
- Views:
Transcription
1 coburg dentistryinc.bsc, DDS Patient Information Dr. Ian C. MacIntyre Name: DOB: (dd/mm/yyyy) / / Telephone: home cell work preferred contact method: Address: Street city province postal code Healthcard: Issuing Province: Emergency Contact: name relation telephone Insurance company policy & ID nº holder s name DOB (dd/mm/yyyy) When was your last dental appointment? What was done at that time? Any specific concerns at this time? How did you hear about us? Privacy statement for patients and consent form Privacy of our patient s personal information is important to us. We are committed to collecting, using, and disclosing personal information responsibly. PERSONAL INFORMATION Personal information for our purposes is; that information necessary for the provision of professional oral health care services provided to you, and information necessary to administer this dental practice. Personal information includes all that information provided by you to us on our patient information/health/medical history form at the first visit and any subsequent visits. Personal information may also include any information provided by you to us during the normal course of communication between patient and dental office staff. We will use and disclose only information provided to us by you or another person acting on your behalf. INFORMATION PROTECTION We are committed to protecting your personal information. We have established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft and unauthorized access. Access to your personal information shall be on a need to know basis. INFORMATION DISCLOSURE Your personal information shall be disclosed to only those who have a need to know and the specific information disclosed shall be restricted to only that information relevant to the recipients need to know. Those who have a need to know include other dentists and health care providers (i.e. dental specialists, personal physicians). Further, the personal information disclosed to dental benefit providers is limited to only that personal information required by the provider. You may at any time designate any restrictions as to whom we may disclose your personal information or restrict the content of a disclosure.
2 INFORMATION RETENTION AND DESTRUCTION We will retain your personal information for the period necessary to continue providing oral health services to you, and for its related administration. We will destroy information in a secure manner when the information is no longer necessary for the provision of oral health services and is not required to be retained for compliance with provincial or federal regulations or statutes. YOUR ACCESS TO YOUR RECORDS We are committed to providing you with open access to your personal information held by us. You may at any time ask us to see your records held by us and to request amendments to that information. We will provide access to you within a reasonable timeframe recognizing your desire for the information and our need to carry on our practice with limited interruption. COMPLAINT PROCESS AND CONTACT Should you wish to make a formal complaint regarding our privacy practices, or have any questions comments or concerns please do so in writing to our privacy officer, Yvette Weeks. We will be pleased to assist you. CONSENT Having read and understood the PRIVACY STATEMENT FOR PATIENTS, I consent to the collection, use and disclosure of my personal information as presented in the STATEMENT, subject to the restrictions identified below. No Restrictions RESTRICTED ACCESS - My personal information shall not be provided to the following individuals or organizations: RESTRICTED INFORMATION - Personal information disclosed from the personal information collected, shall not include: Cancellation and Financial Policy Outside of illness, emergency, or severe weather conditions, twenty-four (24) hours notice is required for cancelling or rescheduling appointments. A fee of $75 may be payable on cancellations without adequate notice and no-shows. In the event of severe weather conditions, illness involving a critical staff member, or emergency situation at our office, we will notify you as soon as we are able. Our policy is to avoid endangering our staff and patients via exposure to these conditions in order to continue providing you with the best care we are able, Arrangements for rescheduling appointments will occur at your earliest convenience, with treatment priority given to those affected by the cancellation. We strive to provide you with the finest oral health care in our office. To accomplish this we work with you and your insurance company to minimize your fees due at the time of evaluation and treatment, and to maximize your reimbursements. For your convenience, we make every effort to direct bill your dental insurance company, if applicable. You will be responsible for the estimated portion of your consultation or treatment that we expect will not be paid by your insurance. This includes copayments and services not covered by your particular insurance. We are pleased to offer many payment methods, including most major credit cards, Interac, and cheques. Please be prepared to provide payment in full for any fees incurred during your visit that day. Occasionally payment plans can be arranged. If you have any questions or concerns regarding your initial or subsequent visits, do not hesitate to contact us. Our administrative staff is friendly and knowledgeable, and can answer your questions regarding insurance and financial issues. Please remember to bring your insurance information with you for your first visit. I have read the above, and agree and understand that I am responsible for all charges relating to my visit.
3 Medical History Do you have or have ever had the following: No Yes Not sure Notes heart condition, murmur, or heart surgery? angina or chest pain? high or low blood pressure? shortness of breath climbing one flight of stairs? asthma, bronchitis, or emphysema? liver disease or problems including jaundice? infectious diseases (Hepatitis, HIV, TB)? bacterial infection resistant to antibiotics (MRSA, VRE)? CJD (mad cow) or family history of disease/carrier status? diabetes? If yes type I or type II thyroid problems? taken or used steroid containing drugs? taken osteoporosis or bone density medications? illicit substances other than marijuana? kidney or urinary problems? epilepsy or seizures? stroke or mini stroke (TIA)? abnormal bleeding or bruising? stomach or duodenal ulcers? indigestion, hiatus hernia, esophageal ulcers? rheumatoid arthritis or osteoarthritis? jaw joint problems? anxiety, depression, or mental illness? malignant hypothermia? If female, are you pregnant or breastfeeding? sleep apnea? snore loudly, feel tired or excessively fatigued during the daytime? List prescribed and non-prescribed medications, doses, and how often you take them Name Dose Frequency Notes
4 List any allergies (medication, antibiotics, latex, egg, others) and your reaction to these substances: List any operations/surgeries you have had, including childhood surgeries such as ear tubes or tonsils: Have you or other members of your family had problems with general anaesthetics (being put to sleep for procedures) other than nausea or vomiting? For example, malignant hyperthermia. Specify: Do you have any family history of bleeding problems, heart diseases, diabetes, or cancer? Specify: Have you been evaluated or treated in a hospital or E.R. in the last 12 months? If yes, specify reason: Do you have any other health problems not listed above? Specify: Do you or did you ever smoke or chew tobacco regularly? If yes, how much? Do you still smoke or chew? Are you interested in quitting tobacco? Do you consume alcohol? If yes, how much and how often? Family Physician: name location telephone Pharmacy: name location telephone I certify that I have read and I understand the questions above and have completed this form to the best of my knowledge. I will not hold my dentist, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form. Reviewed by: name signature date (dd/mm/yyyy)
5 CONSENT FORM & WAIVER I hereby give consent to Coburg Dentistry to provide an intraoral (inside your mouth) and extraoral (outside your mouth in the head and neck areas) examination to determine my treatment needs. Additional diagnostic records and tests may be necessary to provide a diagnosis and develop a treatment plan. These additional records and tests may include (but are not limited to): Radiographs (x-rays) Impressions Models and casts Intraoral and extraoral photographs I understand that bodily tissues (e.g biopsies, extracted teeth) may be removed during the course of treatment. These materials may also be used for any of the purposes outlined below. All records are the property of Coburg Dentistry. I understand that any and all records created in connection with my examination and treatment, including x-rays, impressions, models and casts, intraoral and extraoral photographs during the time of care at Coburg Dentistry may be used for teaching purposes, education, accreditation, examinations and research within the office. I consent to the use of these records for these purposes, which will include disclosing them to students, dental professionals and others who are not providing me with treatment or supervising those who are providing me with treatment. I understand that I must comply with all of the clinic policies and procedures. I have read and understand the Clinic Polices & Patient Information document that has been made available to me at Coburg Dentistry. Coburg Dentistry understands and respects the sensitive nature of the information that you have provided to us. The information is used in compliance with all applicable federal and provincial privacy legislation, the Nova Scotia Dental Board to provide optimal dental care to our patients. I acknowledge that Coburg Dentistry has the authority to discontinue treatment if it has been deemed to be in the best interest of the parties involved. No guarantees or assurance of successful treatment can be made. I understand that Coburg Dentistry will make every effort to provide the highest quality of care but there is a risk of failure. I release Coburg Dentistry from any legal claims for injury, damage or losses suffered while a patient at Coburg Dentistry. Patient Name (print) Signature of Patient Guardian Name (print) Signature of Guardian Date (mm/dd/year) Optional consent for the expanded use of patient records In addition, I also consent to the use of records which may identify me through the use of photographs or other records that may identify me that have been taken as part of my treatment for continuing education purposes or publication outside of the confines of Coburg Dentistry. The purpose includes providing these records to individuals who are not involved in my treatment in any way, including seminars and lectures which involve dental professionals who may not be affiliated with Coburg Dentistry. Sign below ONLY if you agree to the expanded use of your records for these purposes Patient Name (print) Signature of Patient Guardian Name (print) Signature of Guardian Date (mm/dd/year)
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
TRINITY DENTAL CLINIC Medical History Form Date:
Page 1of 4 TRINITY DENTAL CLINIC Medical History Form Date: NAME DATE OF BIRTH ADDRESS CITY STATE ZIP PHONE NUMBERS PHYSICIAN DO WE HAVE PERMISSION TO LEAVE A MESSAGE AT THE PHONE NUMBERS LISTED ABOVE?
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
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
DIRECTIONS TO OUR OFFICE:
8008 Frost St. Suite 300, San Diego, Ca 92123 Office Number: (858)292-5050 DIRECTIONS TO OUR OFFICE: PermaDontics is located at 8008 Frost Street in San Diego off the 163 freeway by Sharp Memorial and
Patient Name Today s Date: Mailing Address Home Phone: City State Zip: Work Phone: Cell Phone: Birth Date: / / Age: SSN: Sex: Male Female
Patient Registration Patient Name Today s Date: Mailing Address Home Phone: City State Zip: Work Phone: Email: Cell Phone: Birth Date: / / Age: SSN: Sex: Male Female Marital Status: Single Married Widowed
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
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:
Patient Name First Middle Last Address Street City State Zip Home Phone Work Phone Cell Phone. Date of Birth SS#
PATIENT WILL NOT BE SEEN WITHOUT PHOTO ID Patient Information Kimberly Walpert, M.D. 1199 Prince Avenue Athens GA 30606 Ph 706-475-1870 Fax 706-475-1879 www.athensbrainandspine.com Patient Name First Middle
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
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 #:
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
Lost/broken filing(s) Teeth grinding/clenching Ringing in ears Broken/chipped tooth Gum disease Stained Teeth Bad Breath Swelling/lumps in mouth
3148 N Swan Rd PATIENT INFORMATION Page 1 Title: Mr. Ms. Mrs. Dr. Name *: Nickname: First MI Last Gender: Male Female Birth Date: Age: Email *: Street *: Apt.: City *: State *: Zip *: Home Phone: Cell
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
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
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
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,
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT You are scheduled to have an appointment at the UPMC Liver Cancer Center which is located in the UPMC Montefiore
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 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:
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
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
Patient Registration Form
Patient Registration Form Please Complete the Following Information-Thank You Patient Information: Name: Last First MI Address: City: State: Zip: Home Telephone: Work Telephone: Best to Reach? Home? Work?
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 # -----
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:
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
LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W
PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS:
PATIENT 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#:
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR 97031 541-387-6125 fax 541-387-6315 Physician Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and
COLON & RECTAL SURGERY, INC.
COLON & RECTAL SURGERY, INC. Please complete attached paperwork and bring to your appointment with your insurance card, co-pay and photo ID. If a referral is required, please be sure to contact your insurance
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
Spouse's Work ( ) Best time and place to reach you _ IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.
PATIENT Date INF\ORMATION W E L ( 0 M DENTAL I NSVRAN(E E Who is responsible for this account? SS/HIC/Patient 10 # Patient ~ Relationship to Patient -----=,,------------- Insurance Co. -------- Address
PATIENT REGISTRATION FORM
Natalie A. Nealeigh, PA-C PATIENT REGISTRATION FORM PATIENT INFORMATION (PLEASE PRINT) Last Name: First Name: MI: Street Address: City: State: Zip: Home #: Cell #: Work #: DOB: Age: Sex (M/F): Marital
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
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
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
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:
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
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
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
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: - -
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
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
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
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: - -
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
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
Welcome to St. Mary s Family Dentistry
Welcome to St. Mary s Family Dentistry We would like to thank you for choosing St. Mary s Family Dentistry as your dental care provider. We are pleased to meet any dental needs you or your family have.
PATIENT INFORMATION. Patient s Name: Birthdate: ( ) F ( ) M LAST FIRST MI. ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed Occupation:
UPON COMPLETION OF PATIENT REGISTRATION PACKET, PLEASE BRING ALL FORMS TO YOUR APPOINTMENT. YOU MAY ALSO FAX COMPLETED FORMS TO THE OFFICE AT 910-575- 9103. THANK YOU. PATIENT INFORMATION Patient s Name:
PATIENT INFORMATION RECORD
Laurence D. Popowich, D.D.S. Robert Laski, D.M.D. Jaime M. Cernansky, D.M.D., M.D. Niral Parikh, D.D.S., B.D.S. Mark H. Grim, D.M.D., Emeritus Diplomates American Board of Oral and Maxillofacial Surgery
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
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
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
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
Statement of Financial Responsibility
Statement of Financial Responsibility Patient Name: Date: Acct : BIR JV, LLP including; Out-Patient, In-Patient and, Home Health Rehab appreciates the confidence you have shown in choosing us to provide
EMERALD ISLE SMILES DENTAL STUDIO WELCOMES YOU
EMERALD ISLE SMILES DENTAL STUDIO WELCOMES YOU ~We Are Honored by Your Call for an Appointment~ A warm welcome from Emerald Isle Smiles Dental Studio! Thank you for choosing us to contribute to your dental
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell
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,
Patient s Name Home Phone # Last First Middle Would you like reminders sent here? Y N Cell # Address City State Zip
PLEASE PRINT PATIENT REGISTRATION DATE: Patient s Name Home Phone # Last First Middle E-mail: @ Would you like reminders sent here? Y N Cell # Address City State Zip Social Security # Birthdate Sex Marital
Louis R. Vita, D.D.S., F.A.G.D. 991 Van Houten Avenue Clifton, NJ Phone:
Louis R. Vita, D.D.S., F.A.G.D. 991 Van Houten Avenue Clifton, NJ 07013 Phone: 973-777-1933 Fax: 973-777-4727 Email: Vitaoffice991@gmail.com Website: DrLouisVita.com We are pleased to welcome you to our
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
New Patient Registration Form NJR_NP_F100
New Patient Registration Form NJR_NP_F100 Patient Last Name First Name Middle Name Maiden Name Address (Street or Box) City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-Mail Patient
WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you
PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell
Tel: Fax:
Laith Farjo, M.D. Providing state of the art orthopedic care in a friendly environment Your Appointment: Time: Please complete the enclosed forms in ink and bring them with you along with your photo ID
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
Male Female Mailing Address: Apt. #: City: State: Zip Code:
Patients ame: (Last, First, MI): DOB: SS: Circle One: / / Male Female Mailing Address: Apt. #: City: State: Zip Code: Driver s Lic or ID #: How would you like to be contacted for appointment reminders?
Welcome to Hawaii Women s Healthcare
Cheryl Lynn T. Rudy, M.D. Cheryl L. Leialoha, M.D. Erin C. Gertz, M.D. Laura A. Spector, D.O. Andrea Wieland, APRN Welcome to Hawaii Women s Healthcare Hawaii Women s Healthcare strives to provide you
Age: Birthdate: Date of Last Physical exam:
Name: : Age: Birthdate: of Last Physical exam: SYMPTOMS: Check symptoms you currently have OR have had within the past YEAR. General Fever Chills Weight loss Weight Gain Headache Depression Vertigo Ringing
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 Demographic Sheet
Patient Demographic Form Please PRINT Patient Demographic Sheet Last name First Name Middle Initial Date of Birth Social Security Number Gender Male Female Marital Status Married Single Divorced Life Partner
DAHIYA FACIAL PLASTIC SURGERY AND LASER CENTER CONSULTATION AND MEDICAL HISTORY. Name Date of Birth Today s Date Address: Street City State Zip
DAHIYA FACIAL PLASTIC SURGERY AND LASER CENTER CONSULTATION AND MEDICAL HISTORY Name Date of Birth Today s Date Address: Street City State Zip Home phone: May we contact you on your home phone? YES NO
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
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
Crescent Community Clinic Application for Healthcare Services
Crescent Community Clinic Application for Healthcare Services If you have been diagnosed with a dental concern, a chronic health or mental health condition, you may be eligible for free healthcare at the
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:
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
PATIENT REGISTRATION
PATIENT REGISTRATION Date: Patient Name Last First Middle Initial (Nickname) Home Address Street Apt# City State Zip ( ) Male ( ) Female Body part being evaluated Marital Status: ( ) Single ( ) Married
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
History Form. PAST SURGICAL HISTORY Surgeries/Hospitalizations Year Complications/Problems with anesthesia
History Form Name: Date of Birth: Today's Date: Height: Weight: Date of Injury: Primary Care Physician: Address Who recommended this office? Address CHIEF COMPLAINT Why are you seeing the doctor today?
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:
PATIENT REGISTRATION
of Appointment: Referring Physician: Denton Watumull, M.D. Derek Rapp, M.D. Joshua Lemmon, M.D. Chase Derrick, M.D. Submit completed form to your patient coordinator s email, print out or email to: Bruce
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:
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************
Workers' Compensation Demographic Form. Patient Information
Workers Comp Patient Demographic Workers' Compensation Demographic Form Please Print Clearly Patient Information Date of Visit Account Number Workers' Compensation Coordinator Patient Name (Last, First,
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
PATIENT INFORMATION. Patient name: Date of birth: Sex: Age: Home address: City: State: Zip: Billing address (if different): City: State: Zip:
PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided
Welcome Please PRINT in blue or black ink.
Renuance Cosmetic Surgery Center Brian Eichenberg, MD Zachary Filip, MD Rachel Ford, MD Plastic, Aesthetic, & Reconstructive Surgery American Association for Accreditation of Ambulatory Surgery Facilities
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
Revised 4/28/2015 Crescent Community Clinic Application for Healthcare Services
Application for Healthcare Services Adults, ages 18 to 64 with no health insurance and limited income you may be eligible for free healthcare at the if you have a chronic health condition, been diagnosed
Patient Registration and Dental History
Patient Registration and Dental History PATIENT INFORMATION DENTAL INSURANCE Date SS/HIC/Patient ID # Patient Name Last Name First Name Middle Name Address Email City State Zip Sex M F Birthdate Married
Flossmoor: (708) Harvey: (708) Tinley Park: (708) ICOR: (708) Crestwood: (708) Patient Signature:
Patient Information Guidelines Department of Outpatient Therapy Services Physical, Speech and Occupational Therapy The staff at Ingalls Outpatient Therapy Services Department is dedicated to providing
MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?
MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET First: MI: Last: of Birth: Age: Gender: Male Female Mailing Address: Physical Address: May we send you text messages relating
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
Written Financial Policy
2316 South Mason Road Katy, TX 77450 Written Financial Policy Thank you for choosing Cinco Ranch Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important
(Please Print) PATIENT INFORMATION. Sex: Male Female Home phone no: ( ) City: State: Zip: Cell phone no: ( ) Occupation: Employer: Work phone no: ( )
(Please Print) Today s date: Primary Care Physician: PATIENT INFORMATION First name: Middle: Last: Former name: Marital Status: Single Married Divorced Widowed Street address: Birthdate: SSN: Email Address:
Welcome to the office of JillAnne W. McCarty, MD, PhD. We are looking forward to meeting you.
Welcome to the office of JillAnne W. McCarty, MD, PhD. We are looking forward to meeting you. For your convenience, attached are forms for you to fill out and bring to your visit. Information on our general
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
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
Surgery Handbook. ! a GUIDE to PREPARING for your OPERATION Lincoln Circle SE Orange City, IA ochealthsystem.org
Surgery Handbook! a GUIDE to PREPARING for your OPERATION Hospital 712.737.4984 Patient Information 712.737.5238 Toll free: 800.808.6264 Fax: 712.737.5252 1000 Lincoln Circle SE Orange City, IA 51041 ochealthsystem.org