Seasons Women s Care Patient Registration Form

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Darren Lewis
5 years ago
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1 Seasons Women s Care Patient Registration Form Name: of Birth: Address: City: St: Zip Home Phone: Cell: Best Number: Race or Ethnicity: Marital Status: SS# Drivers Lic#: Employer: Work# Occupation: Spouse Name: Phone# Employer: Emergency Contact: Phone# Relationship: Primary Insurance Company Name: Subscriber s Name & date of birth, if not patient: DOB: Primary Care Doctor s Name: Phone # Pharmacy Name: Phone# How did you hear about our practice? I certify that the above information is correct, and further authorize the release of any medical information to any insurance carrier for any claim. I request payment of authorized benefits for physician services to the physicians or providers at Seasons Women s Care. I understand that I am responsible for any charges not paid by my insurance company. I also agree that should this account be referred to an agency or attorney for collection, I will be responsible for all collection fees, attorney fees and court costs. I am aware that payment is expected when services are rendered. I am aware that there is a $35 no show fee for appointments. If I need surgery, and the OR is booked, there is a $200 surgery cancellation fee if I cancel. I am also aware that should I need any disability paperwork filled out by my doctor that there is a $35 cash fee charge for this. Signature of responsible party: :

2 Seasons Women s Care - Personal History Form Name: of Birth: Place of birth: Reason for your visit: Please list all prescription medications you are currently taking: Please list all hormones and/or creams you are taking: Please list all vitamins and supplements you are taking: List All Medication Allergies: List all surgeries you have ever had: of Last Menstrual Cycle: Age of First Period: Age of Last Period: Menstrual cycles are heavy, moderate, or light? Period lasts days How often do you get a menstrual cycle? What are you using for birth control (including Vasectomy)? of last Pap Smear: Mammogram: Bone Density: Colonoscopy: List All Pregnancies (including miscarriages and/or abortions): Year: Sex: Vaginal or C-Section: Full Term or Pre Term: Complications: Are you: Married Single Separated Divorced Do you smoke? No Yes How much? How many alcoholic drinks do you have per day? What type of work do you do? What is your sexual preference? M F Are you sexually active? Yes No Have you ever been sexually abused? Yes No Do you leak urine when you cough or laugh? Yes No Family History of Illness (Cancer, Diabetes, etc): Mother: Alive/Well Deceased and/or illness: Father: Alive/Well Deceased and/or illness: Brother: Alive/Well Deceased and/or illness: Sister: Alive/Well Deceased and/or illness:

3 Seasons Women s Care - Personal History Form (cont d) Medical History Please circle any of the following that you have been diagnosed with in the past: Cancer-BRCA Tested Endocrinology-Osteoporosis Psych-Depression Cancer-Breast Endocrinology-Other Psych-Eating Disorder Cancer-Cervical Endocrinology-Thyroid Problems Psych-Other Cancer-Colon Eyes-Cataracts Psych-PMS/PMDD Cancer-Endometrial Eyes-Glaucoma Pulmonary-Asthma Cancer-Lung Eyes-Other Pulmonary-COPD/Emphysema Cancer-Other Cancer-Ovary Eyes-Vision Loss/Macular Degeneration GI-Colon Polyps Pulmonary-Other Pulmonary-Seasonal Allergies/Allergic Rhinitis Cancer-Skin GI-Crohn's/Ulcerative Colitis Pulmonary-Sleep Apnea Cancer-Vaginal GI-Gallbladder Disease Rheumatology-Arthritis Cancer-Vulvar GI-Hemorrhoids Rheumatology-Autoimmune Disease Cardiac-Heart Arrhythmia GI-Irritable Bowel Syndrome Rheumatology- Fibromyalgia/Chronic Pain Cardiac-Heart Disease GI-Liver Disease/Hepatitis Rheumatology-Other Cardiac-High Blood Pressure Cardiac-High Cholesterol GI-Other GI-Reflux/Stomach Ulcers Rheumatology-Restless Leg Syndrome Urology-Frequent Urinary Tract Infections Cardiac-Other GI-Vitamin Deficiency Urology-Hematuria (Blood in Urine) Dermatology-Acne Hematology-Anemia Urology-Interstitial Cystitis Dermatology-Eczema/Psoriasis Hematology-Bleeding Disorder Urology-Kidney Disease Dermatology-Other Hematology-Blood Clotting Disorder/Factor V Leiden Urology-Kidney Infection ENT-Hearing Loss Hematology-Blood Transfusion Urology-Kidney Stones ENT-Other Endocrinology-Diabetes/History of Gestational Diabetes Hematology-DVT/Pulmonary Embolism Psych-ADD Urology-Other Urology-Urinary Incontinence Endocrinology-Elevated Prolactin Psych-Anxiety Disorder Wt Management-Obesity Endocrinology-Osteopenia Psych-Bipolar Disease Wt Management-Other GYN: Abnormal Pap Cervical Dysplasia History of Infertility HPV + Endometriosis Ovarian Problems: PCOS Uterine Fibroids Patient s Signature

4 Seasons Women s Care Forest Hill Blvd., Suite 300 Wellington, FL Notice of Privacy Practices/HIPAA Acknowledgement It is the policy of our practice that all physicians and staff preserve the integrity and confidentiality of Protected Health Information (PHI) pertaining to our patients. The purpose of this policy is to ensure that our practice and its physicians and staff have the necessary medical and PHI to provide the highest quality medical care possible while protecting the confidentiality of the PHI. I acknowledge that I understand my right as a patient of this practice concerning my Protected Health Information (PHI). I am aware Seasons Women s Care reserves the right to change the privacy practices that are described in this Notice of Privacy Practices. I may obtain revised notice of Privacy Practices by contacting the office and requesting a revised copy be sent in the mail or asking for one at the time of my appointment Printed Name of Patient or Personal Representative Signature of Patient or Personal Representative Blood Transfusion Information In rare emergency situations, blood may need to be administered in the course of obstetrical or surgical treatment. Is blood transfusion acceptable in an emergency? Yes No * If no, please explain: *Please be aware that in the event of an emergency, our doctors will give a blood transfusion if deemed necessary in order to save your life and the life of your baby regardless of religious preferences. Signature of Patient or Personal Representative

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: