PATIENT REGISTRATION
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- Todd Chapman
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1 PATIENT REGISTRATION Patient Home Phone ( ) - Address Work Phone ( ) - City State Zip Cell Phone ( ) Birthdate Social Security # - - DL# Address How did you hear about us? Billboard, Phone Book, Intranet, Fly the Flag, Face Book, Individual Other Patient s Employer Employer s Address City State Zip How Long? Phone ( ) Dept. /Ext Spouse s Name D.O.B. Soc. Sec# - - Spouse s Employer Phone # ( ) How Long? Employer s Address City State Zip PERSON TO CONTACT, OTHER THAN SPOUSE, IN CASE OF AN EMERGENCY Name Relationship Address Phone# ( ) What Provider will you be seeing? What kind of insurance do you have? Race: American Indian or Alaskan / Asian / Black / Caucasian / Declined / Other / Pacific Islander Ethnicity: Hispanic / Non-Hispanic / Declined Language: Marital Status: Single Divorced Widowed Married Legally Separated
2 Acknowledgement of Review of Notice of Privacy Practices I have reviewed this office s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. * * Yo he leído la Noticia de Practicas Privadas, que explica como mi información medica será usada y distribuida. Yo entiendo que tengo el derecho de recibir una copia de este documento.* * Patient s Printed Name / * Nombre del Paciente * Patient s Social Security Number Patient s Date of Birth / * Fecha de Nacimiento * Date / * Fecha * Description of Personal Representative / * Relación al Paciente * Additional person(s) authorized to receive any personal information/ *Personas adiciónales a quien podemos dar información personal* I hereby assign to Athens Women s and Children s Center., and any assistant surgeon and/or anesthesiologist of his choice, all money to which I am entitled for medical/or surgical expense relative to the service rendered by him, but not to exceed my indebtedness to said physicians and/or surgeons. I understand I am financially responsible to said doctors for charges not covered by this assignment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and reasonable legal fees should this be required. I authorize any holder of medical information about me to release to my insurance carrier and its agents any information needed to determine these benefits or the benefits payable for related services. * * Yo acuerdo dar a Athens Women s and Children s Center., y cualquier asistente cirujano y/o anestesiólogo de su escoger, todo dinero debido para crujías o asistencia médica relacionado al servicio dado por él, pero que no exceda mi deuda a dichos doctores y/o cirujanos.* * * * Yo entiendo que soy financieramente responsable a dichos doctores por los cargos no cubiertos por este acuerdo. Yo consiento que en dicho caso de que no pague, asumo la responsabilidad de pagar el precio de colección, y/o precio de corte, y/ó precio razonable para asuntos legales si son necesarios. Yo autorizo que mi información médica sea dada a mi seguro medico y sus agentes para determinar la necesidad de estos beneficios ó el pago de estos beneficios ó servicios relacionados. Signature of Patient or Personal Representative / Firma Date / Fecha
3 Accessing your medical information online Your access information To access your medical information, navigate to the Web page listed below and then enter your assigned username and password. Logging in To log in: Name: DOB: Web page: Your username: Your password: 1. Go to the Web page listed above. 2. In the Username field, type your username. 3. In the Password field, type your password. 4. Click the Login button. The patient chart page appears. To view your chart information once you log in: On the left sidebar menu, click the item you want to view. The information appears in the center of the page. Logging out and exiting You should always log out of your online chart when exiting, especially if you are accessing the product from a shared or public computer To log out: Click the Logout link that appears at the top left side of the page. The login screen will appear, verifying that you logged out successfully.
4 I UNDERSTAND THAT MEDICAL PROVIDERS OF THE ATHENS WOMEN S AND CHILDREN S CENTER WHO WILL BE EXAM- INING ME INCLUDE PHYSICIANS, CERTIFIED NURSE MIDWIVES, ADVANCED NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS. Advanced Nurse Practitioners are professional nurses educated to provide the full range of primary care services in the community and hospital settings. They are certified by the American Nurses Association or by nursing specialty organizations. They hold licenses from the state as Registered Professional Nurse Practitioners. Physician Assistants are skilled members of the health care team who are educated to work dependently with physicians and under their supervision provide diagnostic and therapeutic patient care. Certified Nurse Midwives are individuals educated in the two disciplines of nursing and midwifery, who posses certification according to the requirements of the American College of Nurse Midwives. In addition in the state of Texas, they hold license as Registered Nurses and Advanced Nurse Practitioners. I understand that I may request to be seen by a physician. I authorize release of any information required for payment of provider and/or hospital charges for services rendered by the Athens Women s and Children s Center or by one of its clinics. I further authorize release of information to any hospital or medical facility I present myself to for medical care. Yo he leído la información contenida al reverso de esta página en español y creo que la entiendo completamente. Todas mis preguntas en este tema/asunto han sido completamente contestadas. Patient Name Date of Birth Patient s Signature/ Firma del Paciente Date/Fecha Guardian s Signature/Firma del Tutor Date/Fecha
5 NAME: DATE OF BIRTH: REASON FOR VISIT: REFERRED BY: Patient History Form OBSTETRIC HISTORY Year M/F Weight Length of Pregnancy Type of Delivery Problems # of Pregnancies # of Full-Term Deliveries # of Premature Deliveries # of Miscarriages/Ectopics # of Abortions GYNECOLOGIC HISTORY Age of first period: Last menstrual period: Cycles: every days Cycles are: Regular Irregular lasting days Flow is: Light Moderate Heavy Painful Sexual preference: Heterosexual Birth control method: Homosexual Any history of sexually transmitted diseases? Y N Bisexual Last Pap Smear: Any history of abnormal tests? Y N Last Mammogram: Any history of abnormal tests? Y N Last Bone Scan: Any history of abnormal tests? Y N Last Colonoscopy: Any history of abnormal tests? Y N
6 MEDICAL HISTORY Have you ever had any of the following? High Blood Pressure Heart Disease/Attack Stroke Blood Clots High Cholesterol Diabetes Liver Disease Bleeding Problems Asthma Migraines Thyroid Disease Depression/Anxiety Cancer Other: SURGICAL HISTORY Please list all of your surgeries: MEDICATIONS Please list all of your current medications & vitamins: ALLERGIES Please list all of your allergies: None SOCIAL HISTORY Marital status: Religion, if any: Occupation: Any abuse, emotional or physical? Y N Do you exercise? Y N Type & frequency: Do you drink caffeine? Y N How much? Do you smoke? Y N How much? Do you drink alcohol? Y N How often? Do you use drugs? Y N Which ones? FAMILY HISTORY Has anyone in your family ever had any of the following? High Blood Pressure Heart Disease/Attack Breast Cancer Uterine Cancer High Cholesterol Diabetes Colon Cancer Ovarian Cancer Blood Clots Down Syndrome Cystic Fibrosis Tay-Sachs Disease Bleeding Problems Neural Tube Defect Sickle Cell Disease A/B-Thalessemia
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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
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
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
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
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
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
NEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone. Address: Driver s License #:
Patient s Name: NEW PATIENT PACKET Last Middle First Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone Email Address: Driver s License #: DOB: Gender: Male Female
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
YMC Board Application DUE: Friday, May 18, 2018
120 East Jones Street, Suite 110, Santa Maria, CA 93454 26 West Anapamu Street, Santa Barbara, CA 93101 Phone: 805-962-9164 ymc@fundforsantabarbara.org www.fundforsantabarbara.org YMC Board Application
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
Print Patient Name. Patient Signature
. ASSIGNMENT OF BENEFITS Private insurance authorization for assignment of benefits and information release: I, the undersigned, authorize payment of medical benefits to Hill Country Pain for any services
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
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.
107 Commercial Street Mashpee, MA (fax)
107 Commercial Street Mashpee, MA 02649 508-477-7090 508-477-7028 (fax) www.chcofcapecod.org Welcome to your new medical home! We are excited to offer you high quality, integrated health care services
(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:
INITIAL HEALTH SCREENING QUESTIONNAIRE
Welcome to. Now that you are a member, we ask that you please fill out this form. It will help us understand your needs and how to best support you with programs and services. If you need help completing
PATIENT INFORMATION RESPONSIBLE PARTY INFORMATION NAME: DOB: SEX: M / F SOCIAL SECURITY # RELATIONSHIP TO PATIENT: PHONE #: CELL#: EMPLOYER:
PATIENT INFORMATION NAME: DOB: SEX: MALE / FEMALE SOCIAL SECURITY #: MARITAL STATUS: ADDRESS: CITY: STATE: ZIP CODE: PHONE #: CELL#: E-MAIL: PATIENT'S EMPLOYER: OCCUPATION: WORK PHONE: WHERE IS THE BEST
Abortion Day Checklist. Minors
Abortion Day Checklist Patients and support person MUST have Government Issued Picture ID o Bring Government Issued Picture ID o Eat a meal before coming into the health center o Wear a two piece comfortable
PATIENT'INFORMATION'!
PATIENT'INFORMATION'! ' Referred By: Date: PharmacyName,PhoneLocation: LastName: FirstName: MiddleName: DateofBirth: Gender: SSN: MaritalStatus: DriversLicense: PrimaryLanguage: Race: _ AmericanIndian/AlaskaNative
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