Rosati Family Chiropractic Intake Form
|
|
- Joy Carson
- 5 years ago
- Views:
Transcription
1 Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address City State Zip Code Home Phone ( ) - Work Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female Social Security Number: - - Marital Status: Single Married Other Employment Status: Employed Unemployed FT Student PT Student Other Occupation if Employed: Emergency Contact Contact Name Relationship to Patient Contact Home Phone ( ) - Cell Phone ( ) - How did you hear about our office? Have you ever had chiropractic care before? Yes No For what problem? Were the results satisfactory? Yes No N/A Have you seen anyone else for this problem? 1
2 Patient Name Date Medical Conditions: (Check all that apply to you) Arthritis Cancer Diabetes Heart Disease Hypertension Psychiatric Illness Skin Disorder Stroke Other Surgeries: (Check all that apply to you) Appendectomy Cardio-vascular procedure Cervical spine Hysterectomy Joint Replacement Prostate Lumbar spine Gall Bladder Brain Shoulder Thoracic spine Knee Carpal Tunnel Gastro-intestinal Uro-genital Hernia Shoulder Other Allergies: (List any allergies) Please list ALL current medications, vitamins and/or supplements being taken: Social History: (Check all that apply to you) Caffeine use: occasional often never Drink Alcohol: occasional often never Exercise: occasional often never Tobacco Use: occasional often never Sleep: Hours per night = Stress Level: High Moderate Low None Family History: (Check all that apply) Arthritis: Parent Sibling Mental Illness: Parent Sibling Cancer: Parent Sibling Kidney Dis.: Parent Sibling Diabetes: Parent Sibling Ulcer: Parent Sibling Heart Disease: Parent Sibling Asthma: Parent Sibling Hypertension: Parent Sibling Stroke: Parent Sibling Thyroid: Parent Sibling Other 2
3 Patient Name Date Review of Systems (Check if you have had trouble with any of the following within the last 3 months) General: Skin: Cardio: Weight change Rash Murmur Fever Hair Changes Palpitations Chills Nail Changes Cough Night Sweats Itching Chest Pain Fatigue Difficulty Breathing Weakness Blue Extremities Neurologic: Swollen Extremities Eyes: Headache Wheezing Vision Dizziness Pain Convulsions Breasts: Discharge Fainting Mass Discharge G-I: Pain Ears: Appetite Self-exam Hearing Abdominal Pain Ringing Vomiting Pain Diarrhea Psychologic: Discharge Constipation Depression Moods Nose: G-U: Anxiety Pain Frequent Urination Memory Bleeding Painful Urination Taste Musculoskeletal Incontinence Neck Upper Extremities Mouth/Throat: Lower Back Sores Upper Back Bleeding Lower Extremities Taste Additional Info: If you selected headache, please answer the following questions: My headache is located: My headache typically lasts: I experience sensitivity to light when I get my headache: Yes No Sometimes I experience sensitivity to sound when I get my headache: Yes No Sometimes I experience nausea or vomiting before, during or after my headache: Yes No Sometimes I experience headaches: Everyday 1-2 days/week 3-5 days/week Other 3
4 Patient Name Date Are you pregnant? Yes No N/A Major complaints please be specific in describing what brings you in today: When did you first notice this problem/pain? How do you believe this problem/pain began? During the course of the day how often do you experience your symptoms? Intermittently 0-25% Occasionally 26-50% Frequently 51-75% Constantly % By using the key below, indicate on the body diagram where you are experiencing pain: On average rating, from 0-10, how much pain are you experiencing? (0 = no pain and 10 = the worst pain imaginable) Please circle the pain level over the last 24 hours: Please circle the pain avg. level over the last week: Describe your symptoms in order of severity, with worse symptom being #1: Are your symptoms a result of: Motor Vehicle Accident Work related Accident Other How much have your symptoms changed? Getting Better Getting Worse Not Changing In general, my overall health is Excellent Very good Good Fair Poor 4
5 Patient Name Date Activities of Daily Living - Please check if you have pain or difficulty performing the following: Carrying Groceries Change of Position Sit-to-Stand Driving Extended Computer Use Lifting Children Climbing Stairs Bending Feeding Household Chores Kneeling Walking Lifting Reading Self Care Bathing Sleep Sexual Activities Static Sitting Self Care Dressing Pet Care Static Standing Running Yard Work Other Please list all imaging studies (XRAY/MRI/etc.) taken in the last 6 months: My pain/symptoms have previously been made better by: (Check all that apply) Chiropractic Physical Therapy Massage NSAIDS Heat Ice Nothing Pain Medication Movement Exercise Stretching Rest Other: My pain is: (Check all that apply) Worse in the morning Worse during the day Worse at night Worse while sleeping Does not change during the course of the day Intermittent Other: What type of treatment are you looking for? I am looking for the most minimal amount of care to patch up the symptoms of my problem I am looking to resolve my symptoms and then go on to fix the cause of my problem I am looking to take care of my problem and then go on to achieve optimal health and wellness Cancellation Policy We are very pleased to participate in your healthcare, and have set aside time for your appointment. We understand that sometimes it is necessary to cancel or change an appointment. In consideration of the others who need care, we ask that if you are unable to keep an appointment with our office, that you please observe our cancellation policy which follows: Our office requires at least 24 hour notice for all appointment cancelations. If you are unable to provide 24 hour notice, you will be billed a $50.00 charge. Please sign stating you agree to the terms and conditions. Signature Date 5
6 Patient Name Date Payment/Insurance Information: Who is responsible for your bill? Self Health Insurance Spouse Worker s Comp Auto Insurance Medicare Medicaid Other Personal Health Insurance Carrier: Insur. Card ID # Policy Holder s Name: Group # Policy Holder s Date of Birth / / Primary Care Physician Worker s Compensation Injury / Auto / Personal Injury: Have you filed an injury report with your employer? Yes No Date: / / Time: am / pm If Work is responsible, Please fill out the following: Employer Data Name Your Occupation Your Job Description Address City State Zip Code Notice of Privacy Policy for Protected Health Information THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW THIS FORM CAREFULLY AND LET US KNOW IF YOU HAVE ANY QUESTIONS. A COPY OF THIS FORM WILL BE GIVEN TO YOU UPON YOUR REQUEST. Our Duties We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information. Privacy Pledge We respect our patients right to privacy and value your trust. We will never provide your contact or health information to any outside organization for marketing or solicitation. In general, we will not disclose your protected health information without your prior written consent. Some exceptions are listed below. 6
7 Uses and Disclosures for Which Your Consent is Requested 1) Disclosure to another health care provider for referrals for treatment (initial) 2) Disclosure to third party billing, insurance carrier for payment of services (initial) 3) Disclosure to contact you for appointment reminders (initial) May we leave a message on your voic ? Yes / No I consent to the above listed disclosures which I have initialed and I understand that I have the right to revoke this consent, in writing, at any time. Signature: Date: Permitted Uses and Disclosures Without Your Consent Under federal law, we are permitted to use or disclose your health information without your consent in the following circumstances: 1) If we provide health care services to you based on the orders of another health care provider 2) If we provide health care services to you as an inmate 3) If we provide health care services to you in an emergency 4) If we are required by law to treat you and we are unable to obtain your consent prior to doing so 5) If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care 6) If we have reasonable cause to suspect that a child has been abused 7) If you disclose to us your intent to harm another person Your Right to Inspect and Copy Your Health Information You have the right to inspect and/or copy our health information for seven years from the date that the record was created or as long as the information remains in our files. We require that your request to inspect and/or copy your record be made in writing. Your Right to Amend Your Health Information You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains in our files. We require that your request to amend your health information be made in writing and that you give us a reason to support the change that you are requesting us to make. 7
8 Your Right to Receive an accounting of the Disclosures We Have Made of Your Record You have a right to request that we give you an accounting of the disclosures we have made of your record for the last seven years before the date of your request. Re-Disclosure Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. Your Right to Complain You may complain to us or to the Secretary of Health and Human Services is you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take action against you if you do so. HIPAA Privacy Practices I acknowledge that I have received and /or have been given the opportunity to review this Chiropractic Office s Notice of HIPAA Privacy Practices for protected health information. Print Patient s Name Patient s Signature Date Consent to Treat a Minor: (Minor s Printed Name) Guardian / Spouse s Signature Authorizing Care Date SIGNATURE OF PHYSICIAN: Date: Consent to Treatment and Payment Agreement 1. Treatment Consent and Authorization: I consent and authorize Dr. Garett Rosati to examine me and perform all treatments for this and following visits, including, without limitation, performance of diagnostic procedures, examination and all treatment deemed necessary to include but not be limited to; chiropractic manipulation/adjustments, adjunct procedures such as physiotherapy, exercise, therapeutic ultrasound, cold laser, interferential current, Graston Technique, Active Release Technique, Myofascial Release Technique, Kinesio-Tape, Activator or any other treatment by Dr. Garett Rosati. This consent and authorization is given in advance of any specific diagnosis or treatment and is continuing until revoked in writing. I have disclosed all of my past medical history to Dr. Garett Rosati so that an appropriate treatment plan can be developed. I am aware of the risks associated with my treatment, the most common of which is soreness in the treated area, and full and freely accept those risks. I will report any soreness or discomfort that I feel, from the treatment or otherwise, promptly to Dr. Garett Rosati. Any questions I have regarding these treatment procedures, treatment results or treatment alternatives have been answered to my satisfaction prior to my signing this consent form. I have made my decision voluntarily and freely. 8
9 One treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible pop or click, much as you have experienced when you crack your knuckles. You may feel a sense of movement. The material risks inherent in chiropractic treatment As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me. The probability of those risks occurring. Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare. The availability and nature of other treatment options Other treatment options for your condition may include: Self-administered, over-the-counter analgesics and rest Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers Hospitalization Surgery If you chose to use one of the above noted other treatment options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. 2. Insurance Plan Benefits: Dr. Garett Rosati participates with multiple insurance plans. Each insurance plan has different benefit packages and regulations. I understand, acknowledge, and agree that it is my responsibility to be familiar with my insurance benefits and to advise Dr. Rosati s staff regarding my insurance coverage. I understand that Medicare does not reimburse for examinations or re-examinations and agree to pay the fee of $120 on the initial examination date. I understand, acknowledge, and agree that I am fully responsible for all charges, including, without limitation, chiropractic and physiotherapy procedure codes that are not covered by my insurance policy. 3. Payment Agreement and Financial Patient Policies: Dr. Garett Rosati will file the insurance claim(s) with my insurance carrier for services provided to me. I understand, acknowledge, and agree that Dr. Garett Rosati must collect my co-payments and deductibles at the time the service is rendered. If the deductible is not met the patient is responsible for paying a $50 time of service fee for treatment or $100 new patient time of service fee or a combination of the both depending on the services provided on the scheduled visit Upon receiving the patients explanation of benefits the patient will either be credited or billed the difference from what they have already paid at the time of service. The patient is required to present his or her insurance card at the time of visit. Without a current insurance card, Dr. Garett Rosati 9
10 will not be able to file the patient s claims appropriately and the patient will be responsible for the payment of all charges. If my insurance coverage changes, I agree to notify Dr. Garett Rosati at the time of my visit. Dr. Garett Rosati may not be able to re-file claims, and I would be responsible for full payment. Failure to make a payment of a past due invoice after the third notice will result in the claim being handed over to a collections agency. 4. Returned Checks: Dr. Garett Rosati accepts personal checks, cash, Mastercard, Visa, Amex and Discover cards. I understand, acknowledge, and agree that if my check is returned for any reason, a $30 service charge will be charged to my account. Dr. Garett Rosati will require me to pay for all future visits by cash or credit card. PATIENT NAME: DATE: PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW By signing below, I acknowledge that I have read [ ] or have had read to me [ ] and understood all pages, 1 through 10, which include; the Chiropractic Case History, Patient Information, Presenting Problem, Triple (VAS), Review of Systems, Privacy Policy and Consent to Treatment and Payment Agreement of Rosati Family Chiropractic. Dated: Dated: Patient s Name Garett Rosati, D.C. Signature Signature Signature of Parent or Guardian (if a minor) 10
May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female
1 Health Information and Health History Patient Name: Gender: Male Female Marital Status: (Circle one) M S D W Other: Date of Birth / / Spouse Name: How many children: Patient Social Security Number: -
More informationHNS Chiropractic New Patient Intake Form
HNS Chiropractic New Patient Intake Form Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address Line 1 City State Zip Code Home Phone ( ) - Cell Phone
More informationWelcome 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:
More informationWelcome 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:
More informationPATIENT INFORMATION & CONDITION FORM
PATIENT INFORMATION & CONDITION FORM Patient Name: Today's Date: / / Social Security Number Birth Date: / / Age: Gender: F M Email Height : Weight: Specify Right or Left Handed Have you ever been in our
More informationWelcome To Health First Chiropractic
Welcome To Health First Chiropractic Dear Patient: Please complete this questionnaire. Your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will
More informationNew 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 informationCase History/Patient Information
Date: Dr. Lawrence S. Grimm, D.C., A.R.T. Dr. Jason R. Rowenhorst, D.C., A.R.T. 6025 Royal Lane Ste. 6051 Dallas, TX 75230 (P) 214-696-5100 (F) 214-696-5110 Case History/Patient Information Patient Name:
More informationPatient 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 informationPATIENT INFORMATION. Address: Sex: City: State: address: Cell Phone: Home Phone: Work Phone: address: Cell Phone:
PATIENT INFORMATION Name: _ DOB: _ Age: Address: _Sex: City: _ State: _ Zip: _ Email address: Cell Phone: _ Home Phone: Work Phone: _ Responsible Party (if different from above) Name: DOB: Address: E-mail:
More informationPATIENT APPLICATION FOR TREATMENT
PATIENT APPLICATION FOR TREATMENT First Name: M.I.: Last Name: What do you prefer to be called: DOB: Age: Address: City: State: Zip Code: Home #: Cell#: Other: SS#: Sex: Single\Married\Divorced\Widow Spouse
More informationWelcome to Optimum Chiropractic & Wellness Center To The NEW PATIENT Outline of Procedures for Care And Consent to Initiate Care
Welcome to Optimum Chiropractic & Wellness Center To The NEW PATIENT Outline of Procedures for Care And Consent to Initiate Care We are dedicated to providing the highest quality chiropractic health care
More informationSMG 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 informationPatient 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 informationWELCOME 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
More informationPatient 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 informationDOUGLAS 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 informationWITHOUT 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 information5 th Street Chiropractic
5 th Street Chiropractic 5602 East 5 th Street office 520-747-2724 HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
More informationFulcrum 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 informationPATIENT 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 informationCOLON & 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 informationAPPLICATION FOR CARE AT CHIROSOUTH SPINE & SPORT
Whom may we thank for referring you to this office? PATIENT DEMOGRAPHICS Today s Date: - - APPLICATION FOR CARE AT CHIROSOUTH SPINE & SPORT Name: Birth Date: - - Age: Male Female Address: City: State:
More informationPatient 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 informationPATIENT 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 informationPAYMENT 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 informationBellevue Neurology PATIENT DEMOGRAPHIC FORM
PATIENT DEMOGRAPHIC FORM Name Today s date / / Last First M.I. Mailing Address Age Number, Street, Apartment Number City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Date of Birth / / SS # Marital
More informationEntrance Case History (Please write or print clearly)
Stony Brook Medical Park 2500 Nesconset Highway Suite 4-A Stony Brook, NY 11790 (631) 675-9000 Fax (631) 675-9002 www.naturalapproach.us Entrance Case History (Please write or print clearly) Today s Date
More informationAnne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet
Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, 63119 314.484.0690 Patient Data Sheet Date Name: Address: City: State: Zip: Social Security Number: - - Email: Home Phone: ( ) Cell Ph.: ( ) Work Ph.:
More informationFulcrum 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 informationCURRENT HEALTH CONDITIONS
Welcome to Our Office! The following information is needed for our files so we can better serve you as a patient. Please fill in all portions of the term. If you need any help, please ask the receptionist.
More informationLast 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 informationPS CHIROPRACTIC PATIENT CASE HISTORY
PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security
More informationMOTOR VEHICLE COLLISION QUESTIONNAIRE
Patient Name: _ : Address: _ City: _ State: Zip Code: Home Ph #: Work Ph #: Cell Ph #: Email: Sex: M F Marital Status: M S D W of Birth: _ Age: _ Occupation: _ Employer: Your Prior Doctor of Chiropractic:
More informationADULT 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 informationPatient 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 informationAchieving Health Clinic New Patient Information
Achieving Health Clinic New Patient Information Patient Cell# Home# Address City ST Zip E-Mail (please print) For massage appointment reminders do you prefer a: Text or Phone Call? Date of Birth Age Married
More informationPediatric 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 informationPATIENT 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 informationCooley Chiropractic. Date of Birth. Married Single Spouse Name. Street City State Zip. . Name. Occupation. Current Symptoms. When Symptoms began
Please Print Clearly Date NAME: Date of Birth Male Female Married Single Spouse Name Address: Street City State Zip Home Phone Cell Phone E-mail In Case of Emergency please contact: Name Phone Relationship
More informationHEALTH. CENTER Main St NE, Suite 101 PO Box 507 Duvall, WA ph fax Dr. Jeffrey P. Metcalf
Welcome To Our Office Name I prefer to be called First MI Last Home Address: Street City Zip Mailing Address: Street City Zip Phone: ( ) ( ) ( ) Home Cell Work E-mail: Birth : / / Age: Male / Female Marital
More informationPatient 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
More information*Family Chiropractic Care* New Patient Information Worksheet*
*Family Chiropractic Care* New Patient Information Worksheet* Name: SSN: Age: Address: City: State: Zip: Phone Hm: Wk: Date of Birth: E-Mail Employer: Insurance: Policy/I.D. # : Spouses Name: Marital Status:
More informationWelcome to our Chiropractic Office! P l e a s e P r i n t C l e a r l y a n d f i l l I n c o m p l e t e l y.
Welcome to our Chiropractic Office! P l e a s e P r i n t C l e a r l y a n d f i l l I n c o m p l e t e l y. Print Name Email Street Address Phone City State Zip Date of Birth Please Check Sex: Male
More informationJames M. Wilson, M.D. - Medical Information to (fax to ) PATIENT INFORMATION Last name: First: D.O.
James M. Wilson, M.D. - Medical Information Email to wilson@houstonmds.org (fax to 713-790-1605) PATIENT INFORMATION Last name: First: D.O.B: SSN: Age: Gender: M F Home Phone #: Cell Phone #: Work Phone
More informationDear 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 informationPatient Health Information Consent Form
Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any
More informationW e l c o m e t o B i l l e r i c a C h i r o p r a c t i c
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c N E W P A T I E N T I N T A K E F O R M Print Name Today s Date Address City State Zip Email Address Date of Birth Male Female Social Security
More informationFLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty Consent for Purposes of Treatment, Payment and Health Care Operations I consent to the use or disclosure of my protected health information by Florida
More informationSage 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 information2201 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 informationThe 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 informationIntegrative Therapies 7E Oak Branch Drive Greensboro, NC
Integrative Therapies 7E Oak Branch Drive Greensboro, NC 27407 www.integrativetherapies.net 336-294-0910 Hello! Welcome to Integrative Therapies and Integrative Pain Medicine, We are very happy that you
More informationFax: 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 informationWelcome 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 informationName 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 informationNeck & 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 informationWelcome 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 informationPATIENT INFORMATION. Last Name: First Name: MI: Date of Birth: SS #: Gender: Male Female. City: State: Zip Code:
PATIENT DEMOGRAPHIC FORM PATIENT INFORMATION Last Name: First Name: MI: Date of Birth: _ SS #: Gender: Male Female Address: Apt. #: City: State: Zip Code: Home Phone: ( ) - Cell Phone: ( ) - E-mail: Marital
More informationMARATHON PHYSICAL THERAPY & SPORTS MEDICINE. Canton Dedham Easton Newton Norton Norwood Pembroke
Pelvic Floor Physical Therapy Questionnaire Patient Name Answering the following questions will help us to manage your care better. Do you now have or have you had a history of the following? Y/N Bladder
More informationAllergies 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 informationHistory 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 informationPATIENT INFORMATION SHEET:
PATIENT INFORMATION SHEET: LAST NAME: FIRST NAME/MI: ADDRESS: CITY: STATE: ZIP CODE: SOCIAL SECURITY #: HOME: CELL: WORK: SEX: M F BIRTHDATE: MARITAL STATUS: SINGLE MARRIED WIDOWED OTHER EMPLOYER NAME:
More informationInformed Consent for Chiropractic Care
Informed Consent for Chiropractic Care When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both of us to be working toward the same objective. This
More informationGRAHAM 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,
More informationThe 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 informationPATIENT 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 informationMiddle 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 informationNEW PATIENT REGISTRATION FORM
A New Approach to Healthy Living NEW PATIENT REGISTRATION FORM TODAY S DATE: NAME: MALE FEMALE ADDRESS: CITY: STATE ZIP H ( ) C ( ) W ( ) BEST NUMBER TO REACH YOU? WOULD YOU LIKE APPT REMINDERS TO YOUR
More informationJohn L Ledbetter, M.D. Vince R. Forte, M.D. J. Hardy Gordon, M.D. Ronald L. Ellis, M.D.
John L Ledbetter, M.D. Vince R. Forte, M.D. J. Hardy Gordon, M.D. Ronald L. Ellis, M.D. Board Certified Pain Medicine Anesthesiology Patient s Last Name First MI Mailing Address City State Zip Home Phone
More informationBurton M. Sundin, M.D. / Reps B. Sundin, M.D. Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: address:
Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: Email address: Patient Status: 1-Married 2 Single 3-Separated 4-Divorced 5-Widowed 6-Other Birthdate: Sex: Social Security#:
More informationPatient 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 informationFilling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with?
Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with? 1. 2. 3. IMPORTANT PLEASE BRING A COMPUTER DISK WITH ANY BRAIN
More informationColumbia 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 informationAuthorization, Fees, and Office Policy
a Authorization, Fees, and Office Policy Authorization for Treatment I hereby authorize the staff of Compassionate Care Clinics of Pinellas to render medical services as deemed necessary. I also certify
More informationTHE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE
THE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE Authorization for Exchange of Medical Information To Whom It May Concern, I, herby authorize The Center for Headache, Spine and Pain Medicine to receive
More informationPatient History. Name: Date: / / 20. Street Address: City: State: ZIP:
Patient History Name: Date: / / 20 Street Address: City: State: ZIP: Social Security Number: / / Date of Birth: / / Age: Marital Status: Single Married Divorced Widow/er Employer: Occupation: Spouse's
More informationHillcrest Chiropractic Hillcrest Physical Medicine and Rehabilitation Center Check any current conditions General: Respiratory: Neurologist:
ο Nose bleeds Throat: ο Bleeding ο Sore tongue ο Sore throat ο Hoarseness ο Thrush ο Non-healing sores Neck: ο Lumps ο Swollen glands ο Pain ο Stiffness I have reviewed the above information with the patient.
More information2200 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 informationPOTS Treatment Center 7515 Greenville Avenue, Suite 1005 Dallas, TX
Patient Registration: POTS Treatment Center 7515 Greenville Avenue, Suite 1005 Dallas, TX 75231 214-369-8717 Date: Briefly state the medical problem for which you made this appointment today : Name : Address:
More informationWelcome to Purpose Chiropractic wellness with a purpose!
2850 National Drive Suite 105, Onalaska, WI, 54650 (608) 519-5767 www.purposechiro.com Welcome to Purpose Chiropractic wellness with a purpose! About the office Dr. Marty Lorentz Phone: 608-519-5767 Fax:
More informationApplication for Care PATIENT DEMOGRAPHICS HEALTHCARE. Whom may we thank for referring you to this office?
1 Application for Care Whom may we thank for referring you to this office? Today s Date: - - Please fill out these forms in their entirety so the doctors can deliver the highest level of care and get you
More informationDEMOGHRAPHICS INSURANCE INFORMATION
DEMOGHRAPHICS Name: Date of Birth: / / AGE: Street Address: City: State: Zip: Home Phone #: ( ) Cellular Phone :( ) Social Security Number: E-mail: Marital Status: Single Married Divorced Widowed Employer:
More informationBody Basics Physical Therapy Medical History
Body Basics Physical Therapy Medical History Name Date Age Height Weight Hand Dominance: Right/Left Primary Language Do you require an interpreter? Yes/No How did you hear about us? Doctor s First and
More informationNew Patient Paperwork
Your Vision Is Our Focus New Patient Paperwork Dear Patient, Please fill out all of the following pages, and bring them with you to your scheduled appointment time. If you have questions regarding your
More informationPatient 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
More informationPLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Steven J.
More informationWorkers Compensation Demographic
Workers Compensation Demographic 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. Cell Phone o OK to Leave Msg. Email Do
More informationWorkers' 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,
More informationWelcome 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 informationPATIENT 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 informationTODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP DATE OF BIRTH
TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE WORK PHONE MALE FEMALE DATE OF BIRTH EMAIL SOCIAL SECURITY # DRIVERS LICENSE # DRIVERS
More informationPATIENT 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 informationPatient Name Age Date of Birth. Patient Address. City State Zip Code. Home Phone Cell Phone Work Phone
Patient Registration Date Patient Information Patient Name Age Date of Birth Patient Address City State Zip Code Home Phone Cell Phone Work Phone Last 4 Digits of Your Social Security Number Email Marital
More informationSpine Solutions By Donald Mackenzie, MD Relieving the pain Healing the spine Rejuvenating the person
Welcome to by Donald Mackenzie, M.D. Dear Friend, Thank you for choosing me as your spine surgeon. I will personally do everything possible to deserve your trust. I see this as the beginning of a great
More informationName (First): (MI) (Last) Date: Address: City: State: Zip: Home Phone: Cell Phone: Driver s License #: Driver s License State: Occupation:
Board Certified & Fellowship Trained in Sports Medicine & Orthopaedic Arthroscopic Surgery 9980 Central Park Blvd North, Suite 222 Boca Raton, FL 33428 Please Print: Name (First): (MI) (Last) Date: Address:
More informationNPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:
More informationPatient 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 informationMEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB. Please answer the following questions about your current eye problems and medical history:
MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB Please answer the following questions about your current eye problems and medical history: 1. What problems are you CURRENTLY having with your
More informationWelcome to Rebound Sports & Physical Therapy!
Welcome to Rebound Sports & Physical Therapy! We are happy you chose us to assist with your care. We strive towards providing an excellent experience for all our patients as we assist you in regaining
More information