Please allow us hours to refill the medication; approval from your medical provider is required on all refills.

Size: px
Start display at page:

Download "Please allow us hours to refill the medication; approval from your medical provider is required on all refills."

Transcription

1 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 of care more efficient. Prescription refills We ask that our patients contact their pharmacy for any medication refills. Please call a week prior to the medication being needed so that they have time to contact us if necessary. We accept faxes at (919) , 24-hours a day. Please allow us hours to refill the medication; approval from your medical provider is required on all refills. Please contact your pharmacy at 72-hours to ensure they have received the refill authorization. Please do not call the nurses to verify completion. Patients that need refills for any controlled substance may continue to call our office as previously directed. As always, our nurse will call when the prescription is ready for pick up. Test results Our nurses are given explicit direction by the medical providers on every patient s test results. Results will be mailed to your home within 14 business days for normal test results. Any patient with abnormal labs will be called by our nursing staff under the direction of the medical providers. These results will be called within five business days depending on the severity of the abnormality. Our nurses prioritize abnormal lab results and will make three attempts at calling, if there is no response, a letter will be mailed asking you to call our office. If you have any additional questions regarding your labs, you may be asked to make a follow-up appointment with your medical provider to discuss your concerns in detail. Physical exams A physical exam or wellness visit is a great time to ensure your overall health is at its best. If you have any new health concerns you that need to address during a physical exam or wellness visit, please note that you may be charged an office visit in-conjunction with the physical exam. This may prompt an out-of-pocket expense. (919) rexhealth.com/holly-springs-primary-care 781 Avent Ferry Road, Suite 206 Holly Springs, NC 27540

2 Physical exam labs At the patient s request, for exams scheduled at least 14 days in advance, we will mail you a lab order along with fasting instructions and a list of labs. If your exam is scheduled less than 14 days in advance, you will be given the lab order on the day of your physical exam. No results for labs performed prior to the exam will be given unless there is a significant abnormal value. Form completion We are happy to complete forms for our patients. We ask that you drop the form off and allow five business days for completion. Our nursing staff will call you when the form is complete and ready for pick up. We are unable to complete any form for patients who have not received a yearly physical in the last 12 months. Some forms may require an office visit to be completed properly. Cancellation and no-show Appointments must be cancelled at least 24-hours prior to the scheduled appointment time. A no-show fee may be assessed for any patients not calling to cancel. In the event a patient has incurred three documented no-shows, and/or late cancellations the patient can be discharged from the practice. Messages left for nurses and after hours phone calls During regular office hours, our telephone will be answered by our staff. We will make every effort to return calls within 24-hours. Calls requiring review by a medical provider may take up to 72-hours. After hours and on weekends, our answering service receives calls and forwards them to the covering board-certified family physician. If you are having an emergency, including chest pain, shortness of breath or abdominal pain, call 911. Referrals Many insurance plans do not require a referral from your primary care provider to see a dentist, ob-gyn, dermatologist or other specialist. If a referral is required we will provide one, but occasionally an office visit is required first. If we are recommending you to see a specialist, please allow five business days for the nurses to complete the process. The office we refer you to will contact you directly to schedule an appointment. Thank you for the opportunity to care for you and your family! (919) rexhealth.com/holly-springs-primary-care 781 Avent Ferry Road, Suite 206 Holly Springs, NC 27540

3 REX PRIMARY CARE OF HOLLY SPRINGS NOTICE OF SEPARATE BILLING The physician may order Laboratory and/or Radiology services for you while you are in our facility. Although the services are performed in this facility, the Laboratory and Radiology are extensions of the hospital and you will receive a separate bill from them. We do not bill for x-rays and lab tests. Billing for Laboratory services is done by Rex Outreach Laboratories, not through this office. Please be advised that some insurance companies mandate where your lab tests can be performed. The physician in this facility may be in-network with your insurance company but Rex Laboratory may not be. The same may be true with LabCorp or other outside Laboratories that your insurance does not cover. Billing for Radiology services is done by Rex Hospital, not through this office. Radiology services are billed in two parts. The first part of the bill is for the service itself, and a bill from Rex Hospital will be sent to you for the actual testing. You will also receive a bill from Raleigh Radiology for the professional reading by a radiologist. Some insurance companies may also apply lab and/or x-ray charges to your deductible. If you have questions as to whether your charges will be managed in this manner, please consult with your insurance company. If you have any questions, please ask our staff at check-out. Thank you for choosing Rex Primary Care of Holly Springs. Patient/Guardian Signature Date (01/08)

4 (rev 1/5/2012) Date: REX PRIMARY CARE OF HOLLY SPRINGS 781 Avent Ferry Road, Suite 206 Holly Springs, NC Phone: (919) Fax: (919) Patient Acct No I. PATIENT INFORMATION Lab/Radiology Information SS# Last Name First Name MI Street Address City State Zip Home Phone Work Phone Cell Phone Date of Birth Sex Male Female Marital Status Race Employer Employer Address Phone Number Mother s Maiden Name Father s Name Contact Person in Case of Emergency Phone Number Pharmacy Name, Address & Phone # II. POLICY HOLDER INFORMATION (Other than Patient) SS# Last Name First Name MI Street Address City State Zip Relationship to Patient Home Phone Cell Phone Date of Birth Sex Male Female Marital Status Race Employer Employer Address Phone No III. PARTY/PERSON ACCOMPANYING A MINOR SS# Last Name First Name MI Street Address City State Zip Relationship to Patient Home Phone Cell Phone Date of Birth Sex Male Female Marital Status Race Employer Employer Address Phone No IV. MEDICAL INSURANCE INFORMATION Primary Insurance Policy Holder Secondary Insurance Policy Holder Card(s) attached Verified Updated Initials/Date Patient Signature: Date:

5 NAME: Rex Primary Care of Holly Springs - HEALTH QUESTIONNAIRE DATE: Family History ALIVE & WELL CAUSE & AGE OF DEATH DECEASED Hypertension Heart Disease Diabetes Cancer Prostate Prob Stroke Cholesterol Asthma/Lung Kidney Disease Arthritis or Gout Migraine/Seizure Depression/Anxiety Anemia Dementia Blood clots Smoker OTHER Alcohol/Drug Abuse FATHER MOTHER Brother / Sister Brother / Sister Brother / Sister Brother / Sister Mother's Relatives Father's Relatives SPOUSE HOSPITAL ADMISSIONS and SURGERY YEAR NAME MEDICATIONS DOSE HOW OFTEN NAME DOSE HOW OFTEN ALLERGIES: SOCIAL HISTORY YOUR MEDICAL HISTORY Check box for current or past problems with: Smoke: packs x yrs- Stopped: Caffeine: cups/day Eye Problems Bowel Problems Thyroid Problems Seizures Onset Age: y/o Hearing Problems Liver Problems Arthritis Tremors/shaking Regular or Irregular Throat problems Cancer: Migraine Muscle weakness # Days: Hvy Med Light Lung Problems Bladder Problems Skin Problems Numbness or tingling Pain: Severe Mod Min Heart Problems Kidney Problems Sleeping Problems Gout Birth Control: High blood pressure Prostate Problems Use of drugs (IV, other) Excessive fatigue # Children: Circulation Problems Leg/Back/Neck Pain HIV-AIDS Nervous / Depressed # Pregnancies: Blood Clots Weight Loss or Gain Sexually transmitted infection Memory Problems Painful Intercourse Bleeding Problems Anemia Transfusions or Tattoo Abnormal Pap History Ulcer/ GERD Problems Diabetes Use snuff or chew tobacco Bleed between periods When was your last: Beer/Wine/Alcohol: Labs: Chest Xray: Flu shot: Pap test: Prostate exam: Abnorm Mammogram History EKG: TB test: Tetanus: Mammogram: Colonoscopy: Breast Biopsy History Stress Test: /day /wk Cardiac Cath: Pneumonia shot: Bone Density: Female Menstrual History Menopause: y/o Do you: Exercise Routinely: Y N Use Seatbelt: Y N r History of Hormone Use Comments: rev 5.09

6 Consent to Treatment I am a patient at UNC Physicians Network (UNCPN). By signing this form, I give my consent to be treated by the doctors of this practice. My doctor needs medical facts about my health. I,, ask for and allow the doctors and staff of UNCPN to give me the needed medical treatment and services they recommend. I understand treatment and services may include: lab tests, screening tests (tests that can find an illness early, before a person shows signs of having the disease), diagnostic tests (tests that shows if a person has a certain illness or health problem), and routine exams. My doctor may need to photograph or videotape me to learn more about my health problem. I understand that no promises have been made to me about the results of any treatment or services. Release of Health Information UNCPN may release my health information to other doctors and staff who treat me. This could include healthcare providers who treat me who are not part of UNCPN. UNCPN may release my health information to insurance companies or other companies that UNCPN uses to bill for services. UNCPN may release my health information to companies that help UNCPN improve the quality and cost of care provided to patients by reviewing the health care provided by the practice. If I cannot be reached, a representative of UNCPN can give information about my test results, my care or my bills to: Name: Relationship: Phone Number: Name: Relationship: Phone Number: I do NOT want my information given to my family, friends or others. UNC Physicians Network Consent to Treatment

7 Financial Policies The doctors and other healthcare providers of UNCPN charge fees for the care provided to me. The fees may not be exactly the same as the estimate given to me. I know that my health insurance company may not pay the full amount of the fees charged by UNCPN. This means I may have to pay UNCPN for the cost of care that is not paid by my health insurance company. If I have not given UNCPN the right health insurance information, then I may have to pay the fees for my care. If I do not have health insurance, then I will have to pay the fees for my care. If I have paid UNCPN too much money for my care, then the dollar amount can be used to pay the balance of some other account that I have with UNCPN. Medicare will only pay for the care that is acceptable and needed under section 1862(a)(1) of the Medicare Law. The facts I have given to UNCPN for payment under Titles XVIII and XIX of the Social Security Act are correct. UNCPN can bill my health and liability insurance companies for my care. Payments will be made to UNCPN on my behalf. Social Security Number I voluntarily give UNCPN the last four digits of my social security number, if needed, to identify me and file bills with my insurance company. UNCPN will follow any federal and state laws about the use and protection of my social security number. Personal Items UNCPN is not responsible for taking care of my personal items. This includes items such as jewelry, eyeglasses, hearing aids, dentures, clothing, and cell phones. I know that I must take care of my personal items. Notice of Privacy Practices The Notice of Privacy Practices tells me my rights as a patient of UNCPN. This includes how my medical records are protected at all doctors offices. I have been given a copy of UNCPN s Notice of Privacy Practices. UNC Physicians Network Consent to Treatment

8 I prove with my signature below that: Patient Acknowledgement the above facts that I have given to UNCPN are correct, I have read and understand all of the facts stated above, I have had the chance to ask questions about the facts in this form, and all of my questions have been answered. I know that I will be asked to sign this form again if I am still a UNCPN patient in one year. I know that I may withdraw this form by writing to UNCPN. This may change actions that UNCPN is taking or may have taken. I consent to treatment as a patient of UNCPN. Signature of Patient or Responsible Party Relationship (if not Patient) Witness Date and Time Printed Name (if not Patient) Date and Time UNC Physicians Network Consent to Treatment

9 I authorize: (Check One) UNC Physicians Network: Name of Person or Facility: Address, City, State, ZIP: AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION **Important-Please mail records if over 10 pages** Phone: Fax: To use or disclose to: Name of Person or Facility: Address, City, State, ZIP: Phone: Fax: The MEDICAL RECORD (Protected Health Information) OF: Patient Name: Address, City, State, ZIP: Date of Birth: Phone: Medical Record #: SSN (last four): Treatment Dates From: Put a CHECKMARK next to the specific documents that apply to your request: to Clinic Notes Radiology Reports Nurses Notes Emergency Room Progress Notes Lab Reports Urgent Care Doctor Consults History & Physical Pathology Reports Operative Reports Other Discharge Summary Physician Orders EKG, EEG, EMG Place your initials in the applicable boxes below to authorize the release of SENSITIVE information pertaining to: Mental Health Drugs & Alcohol Put a CHECKMARK next to the purpose of the request: HIV/AIDS/ other infectious diseases Genetic Testing Not Applicable: None of these apply Continued Patient Care Social Service / Disability Insurance Other: Personal Attorney / Legal Worker s Compensation Put a CHECKMARK next to how you would like to receive your request: Mail to address above. Verbal release Fax to # listed above (Urgent or Prioritized) Pick up at Practice I UNDERSTAND THAT: I may revoke this Authorization at any time: o the revocation will not apply to information that has already been released in response to this Authorization o I must revoke this Authorization in writing. The procedure for revoking this Authorization is to present my written revocation to the UNC Physicians Network Compliance Manager. I may refuse to sign this Authorization: o My treatment, payment, enrollment in a health plan, or eligibility for benefits cannot be conditioned upon my authorization of this disclosure. o A fee may be charged for copying the protected health information. Please contact Compliance Manager to obtain fee and rate I have been informed and understand that information disclosed pursuant to this Authorization may be subject to re-disclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no longer be protected under federal medical privacy law. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:. If I fail to specify an expiration date or event or condition, this authorization will expire automatically in ninety (90) days from the date of signature. I have read and understand the information in this Authorization form. Signature of Patient: Printed Name: Signature of Authorized Representative: Printed Name: Please explain Representative s authority to act on the behalf of the Patient: Processed Date: Processed By: OFFICE USE ONLY Stamps / Additional Notes: Date: Date:

Sage Medical Center New Patient Forms

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

More information

Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:

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

More information

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

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

More information

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

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:

More information

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. 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: - -

More information

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. 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: - -

More information

ADULT PATIENT INFORMATION. Patient Name: Last Name First Name Address: City: State: Zip Code: Phone #: Cell Phone #: Social Security:

ADULT PATIENT INFORMATION. Patient Name: Last Name First Name Address: City: State: Zip Code: Phone #: Cell Phone #: Social Security: 716 S. Goldenrod Road n 3315 Orange Blossom Trail Fax (407) 658-2536 Fax (407) 343-1907 ADULT PATIENT INFORMATION Patient Name: Last Name First Name MI Address: City: State: Zip Code: Phone #: Cell Phone

More information

The Home Doctor. Registration Checklist

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

More information

Welcome to University Family Healthcare, PA.

Welcome to University Family Healthcare, PA. Welcome to University Family Healthcare, PA. We re delighted that you have chosen us as your primary care providers. We work hard to earn your trust and to see that you have the best healthcare possible.

More information

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name

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

More information

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address

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

More information

PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip

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

More information

Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?

Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have? Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic

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

New Patient Registration Form NJR_NP_F100

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

More information

Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?

Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have? Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic

More information

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

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

INSURANCE INFORMATION

INSURANCE INFORMATION 2014 575 Hill Country Dr. Ste 202 Kerrville, TX 78028 (830)258-6237 Office (830)315-1366 Fax Patient Name (last, first, MI) of Birth Social Security Number Mailing Address Home Telephone Work Telephone

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Email address Patient Information Street Address City State Zip Home Phone SSN Date of Birth Gender Male Female Work Phone Cell Phone

More information

PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!

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

More information

Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.

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

More information

ObGyne Consultants ObGyne After Hours Middle Georgia Immediate Care Center

ObGyne Consultants ObGyne After Hours Middle Georgia Immediate Care Center 1 ObGyne Consultants ObGyne After Hours Middle Georgia Immediate Care Center http://obgyneconsultants.com http://obgynepatientnews.com Macon 639 Hemlock St. Macon, GA 31201 P: (478) 745-3014 F: (478) 745-9887

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

DRUG / MEDICATION ALLERGIES: (include: Type/Reaction)

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

More information

DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group

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

More information

(Please Print) PATIENT INFORMATION. Sex: Male Female Home phone no: ( ) City: State: Zip: Cell phone no: ( ) Occupation: Employer: Work phone no: ( )

(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:

More information

ALFRED ALINGU, MD INTERNAL MEDICINE

ALFRED ALINGU, MD INTERNAL MEDICINE Name Date of Birth Social Security Number Marital Status Address City State Zip Code Home Phone Cell Phone E-mail Address Pharmacy Name Pharmacy Phone Number Emergency Contact Phone Number Relationship

More information

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:

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:

More information

Print Guardian Name (If not patient) DOB: Patients Name: (Last, First, MI): Circle One: - - / / Mailing Address: Apt. #: City: State: Zip Code:

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:

More information

The Providers and Staff of Baptist Medical Group Primary Care- LiveOak BAPTISTMEDICALGROUP.ORG. Primary Care - Live Oak.

The Providers and Staff of Baptist Medical Group Primary Care- LiveOak BAPTISTMEDICALGROUP.ORG. Primary Care - Live Oak. BAPTISTMEDICALGROUP.ORG Primary Care - Live Oak Dear Patient, Thank you for choosing Baptist Medical Group Primary Care - Live Oak to provide you with compassionate care for your health care needs. We

More information

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 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

More information

Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:

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

More information

Adult Health History

Adult Health History Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure

More information

Page 1 of 5 1/4/17. Print Guardian Name (If not patient) DOB: Circle One: - - Patients Name: (Last, First, MI):

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:

More information

Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self

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)

More information

Seasons Women s Care Patient Registration Form

Seasons Women s Care Patient Registration Form Seasons Women s Care Patient Registration Form Name: of Birth: Address: City: St: Zip Home Phone: Cell: Best Number: Email: Race or Ethnicity: Marital Status: SS# Drivers Lic#: Employer: Work# Occupation:

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

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

Name DOB / / SS# / / Street Address City/State/Zip. Home ( ) - Cell( ) - Work( ) - Emergency Contact Day Phone( ) -

Name DOB / / SS# / / Street Address City/State/Zip. Home ( ) - Cell( ) - Work( ) - Emergency Contact Day Phone( ) - Wellesley Women s Care, P.C. PPG Thank you for taking the time to complete this form. We ask that you complete this entire form once a year or when you have any NEW information. PATIENT INFORMATION (Please

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

PATIENT INFORMATION INSURANCE INFORMATION

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

More information

PATIENT INFORMATION When registering please provide proof of insurance and Picture ID Payment is expected at time of service.

PATIENT INFORMATION When registering please provide proof of insurance and Picture ID Payment is expected at time of service. KENTUCKY FERTILITY, GYNECOLOGY AND OBSTETRICS PRIMARY HEALTH CARE 170 North Eagle Creek DR Suite 101 Lexington KY 40509 Phone 859-277-5736 Fax 859-276-2236 PATIENT INFORMATION When registering please provide

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

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

Welcome to Hawaii Women s Healthcare

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

More information

To All Mission Ranch Primary Care Patients:

To All Mission Ranch Primary Care Patients: To All Mission Ranch Primary Care Patients: At Mission Ranch Primary Care we strive to provide the best possible customer service. As a part of this, we ask that you fill out this paperwork and return

More information

History Form. PAST SURGICAL HISTORY Surgeries/Hospitalizations Year Complications/Problems with anesthesia

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?

More information

Patient Name First Middle Last Address Street City State Zip Home Phone Work Phone Cell Phone. Date of Birth SS#

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

More information

WILMINGTON HEALTH Patient Information

WILMINGTON HEALTH Patient Information WILMINGTON HEALTH Patient Information Account No. Doctor s No. PLEASE ANSWER ALL QUESTIONS PATIENT INFORMATION NAME: LAST BIRTHDATE SS# HOME PHONE CELL PHONE EMAIL ADDRESS FIRST MIDDLE SEX M F RACE White/Caucasian

More information

PATIENT REGISTRATION FORM (ecw)

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:

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

Flossmoor: (708) Harvey: (708) Tinley Park: (708) ICOR: (708) Crestwood: (708) Patient Signature:

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

More information

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 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 # -----

More information

Social Security Number: Employment Status: Employed Unemployed Address: Student Retired

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

More information

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country

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

More information

COLON & RECTAL SURGERY, INC.

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

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

School Based Health Consent for Services Grace Community Health Center, Inc.

School Based Health Consent for Services Grace Community Health Center, Inc. School Based Health Consent for Services Grace Community Health Center, Inc. Please read carefully: In order for us to see your child in school based clinics, all pages of this form must be completed by

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

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

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:

More information

Pediatric New Patient Form

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

More information

2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name

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

More information

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) 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

More information

PATIENT INFORMATION. Patient s Name: Birthdate: ( ) F ( ) M LAST FIRST MI. ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed Occupation:

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:

More information

Responsible Party (Guarantor) Info. Insurance Information

Responsible Party (Guarantor) Info. Insurance Information Associates in Women s Health, P.C. 2801 YOUNGFIELD STREET, SUITE 200 GOLDEN, CO 80401 P: 303-940-1867 F: 303-940-1894 Please Circle Your Doctor: ELLIS GANTER PYTHON SCHOEN WESSELL, WHNP PATIENT INFORMATION

More information

Women s Specialty Care, P.C 682 Hemlock Street Suite 300 Macon GA WELCOME

Women s Specialty Care, P.C 682 Hemlock Street Suite 300 Macon GA WELCOME Women s Specialty Care, P.C 682 Hemlock Street Suite 3 Macon GA 3121 478-744-9683 WELCOME Thank you for choosing Women s Specialty Care, P.C. for your OB/GYN needs. We ask that you complete all of the

More information

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 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

More information

PATIENT REGISTRATION. Street City State Zip WORK INJURY/ ACCIDENT

PATIENT REGISTRATION. Street City State Zip WORK INJURY/ ACCIDENT PATIENT REGISTRATION, Last First M.I. SEX: Male Female DOB: / _/ AGE: MARITAL STATUS: SS#: - - PHYSICIAN: ADDRESS: Street City State Zip (HOME) (WORK) TEL: - - TEL: - _- CELL: - _- EMAIL: PRIMARY INSURANCE:

More information

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 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

More information

Your annual preventive visit, or complete physical exam, is scheduled with. Dr. on at AM/PM.

Your annual preventive visit, or complete physical exam, is scheduled with. Dr. on at AM/PM. Dear: Your annual preventive visit, or complete physical exam, is scheduled with Dr. on at AM/PM. Please bring the following with you on the date of your appointment: A list of your current medication(s),

More information

Tel: Fax:

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

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

Patient Registration Form

Patient Registration Form 908 South 10 th Street Office: 337.392.2330 Fax: 337.392.2580 West State Orthopedics and Sports Medicine Clinic, LLC Patient Registration Form Date: / / Patient Name: Birth Date: / / (last) (first) (mi)

More information

New Patient Intake Form

New Patient Intake Form Phone: (336) 538-0089 Fax: (336) 538-0097 Burlington, NC 27253 New Patient Intake Form Provider: Dr. Martin DeFrancesco Melody Burr Lindsey Overton Patient Name: DOB: Marital Status: Single Married Divorced

More information

TRINITY DENTAL CLINIC Medical History Form Date:

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?

More information

M or F Patient s Date of Birth Patient s Social Security Number Sex. Secondary Address: (if have, Northern) Street City State Zip Code

M or F Patient s Date of Birth Patient s Social Security Number Sex. Secondary Address: (if have, Northern) Street City State Zip Code PATIENT REGISTRATION PLEASE PRINT Today's Date: Referred by: Patient s Name: Last First M.I. M or F Patient s Date of Birth Patient s Social Security Number Sex Primary Address: Street Apt/Unit # City

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

Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:

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:

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

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

Patient Name: First Middle Last Address: City: State: Zip Code: Date of Birth: Social Security: Marital Status: S M D W

Patient Name: First Middle Last Address: City: State: Zip Code: Date of Birth: Social Security: Marital Status: S M D W Date: Sex: M or F Patient Name: First Middle Last Address: City: State: Zip Code: Date of Birth: Social Security: Marital Status: S M D W Home Phone: Work Phone: Cell Phone: Email Address: Employment Status:

More information

Dodge. County. Schools

Dodge. County. Schools Welcome to the Dodge School Based Health Clinic. Dodge Board of Education and Dodge Connection-Communities In of Dodge, Inc. are continuing to move forward with our goal of serving the children and families

More information

Renée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD

Renée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD Renée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD RHEUMATOLOGY CONSUTLATION ARTHRITIC CONDITIONS AUTOIMMUNE DISEASES MUSCULOSKELETAL ULTRASOUND Name: First Name Last Name Social Security Number: Sex:

More information

PATIENT REGISTRATION

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

More information

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. 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

More information

PATIENT REGISTRATION FORM

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

More information

Dear New Patient: Sincerely, The Scheduling Staff

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

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

Norman H. Anderson M.D., P.A. Robert Boissoneault Oncology Institute INSURANCE AUTHORIZATION

Norman H. Anderson M.D., P.A. Robert Boissoneault Oncology Institute INSURANCE AUTHORIZATION Norman H. Anderson M.D., P.A. D/B/A Robert Boissoneault Oncology Institute 2020 SE 17 th Street Ocala, Fl 34471 522 N. Lecanto Highway Lecanto, FL 34461 605 W. Highland Blvd. Inverness, FL 34452 9401 SW

More information

SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely)

SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely) SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely) Name: Former/ Maiden Name: Date of Birth: Age: Today s Date: *Language: Race: Ethnicity: *Do

More information

Fax: Do not mail the forms!

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

More information

Neck & Spine Patient Demographic

Neck & Spine Patient Demographic Neck & Spine Patient Demographic o New Patient o Return Patient o Update Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg.

More information

Dr. Ian C. MacIntyre

Dr. Ian C. MacIntyre coburg dentistryinc.bsc, DDS Patient Information Dr. Ian C. MacIntyre Name: DOB: (dd/mm/yyyy) / / Telephone: home cell work email: preferred contact method: Address: Street city province postal code Healthcard:

More information

2200 Northern Boulevard, Suite 133 East Hills, NY Fax (516) Transitional Care

2200 Northern Boulevard, Suite 133 East Hills, NY Fax (516) Transitional Care 2200 Northern Boulevard, Suite 133 East Hills, NY 11548 855-670-6077 Fax (516) 918-9039 Transitional Care Dear New Patient: We welcome you to our practice as a transitional patient. We will be managing

More information

Welcome to Fosston Chiropractic Clinic, P.A.

Welcome to Fosston Chiropractic Clinic, P.A. Welcome to Fosston Chiropractic Clinic, P.A. www.fosstonchiro.com Chiropractic Acupuncture Sport and Spinal Rehabilitation Thank you for choosing us for your chiropractic care. Please complete this form.

More information

Patient Information: Last Name First Name MI. Address Apt/Room # City Zip. Community name (if not at home) Martial Status: S M W D

Patient Information: Last Name First Name MI. Address Apt/Room # City Zip. Community name (if not at home) Martial Status: S M W D HouseCalls-MD 2998 W. Montague Ave. Suite 117 N. Charleston, SC 29418 Info@housecalls-md.com Office 843-501-2031 www.housecalls-md.com Fax 888-453-0810 Patient Information: Last Name First Name MI Gender

More information

Date. Dear. Thank you for scheduling your appointment with us on to welcome you to Lighthouse Family Medicine.

Date. Dear. Thank you for scheduling your appointment with us on to welcome you to Lighthouse Family Medicine. Date Dear Thank you for scheduling your appointment with us on to welcome you to Lighthouse Family Medicine.. It is our pleasure Enclosed you will find a new patient information packet. Please complete

More information

Welcome to Mid-State Health Center. Our Promise to You. Locations and Hours. After-Hours Access

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

More information

Welcome Letter- Orchard School Clinic

Welcome Letter- Orchard School Clinic Welcome Letter- Orchard School Clinic Dear Parent or Guardian: Orchard School Clinic is a school-based location of RiverStone Health Clinic. This is a collaborative effort between RiverStone Health, Billings

More information