Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)
|
|
- Grace Allison
- 5 years ago
- Views:
Transcription
1 PEDIATRIC ASSOCIATES OF MADISON 21 Hughes Rd., Suite 2 Madison, Alabama Fax Tonya T. Zbell, M.D. Robbie F. Dudley, M.D. Charlotte M. Meadows, M.D. Cynthia Dill, M.D. Elizabeth M. Bryant, M.D. Jessica Magnusson, M.D. Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER) PATIENT ADDRESS STREET CITY, STATE ZIP CODE PRIMARY CONTACT AND APPOINTMENT REMINDER PHONE # PARENT INFORMATION DAD S NAME DAD STEP DAD MOM S NAME MOM STEP MOM ADDRESS ADDRESS DAD S CELL PHONE # MOM S CELL PHONE # DOB SOCIAL SECURITY # DOB SOCIAL SECURITY # EMPLOYER WORK PHONE NUMBER ADDRESS - May we add you to our list? yes no EMPLOYER WORK PHONE NUMBER ADDRESS - May we add you to our list? yes no EMERGENCY CONTACT (FRIEND OR RELATIVE) NAME RELATIONSHIP HOME PHONE CELL PHONE REFERRED BY:
2 CONTINUE ON BACK >>>>>>>>> INSURANCE INFORMATION PRIMARY INSURANCE POLICY HOLDER S NAME DOB SSN COPAY PRIMARY INSURANCE CO. POLICY NUMBER GROUP NUMBER SECONDARY INSURANCE POLICY HOLDER S NAME DOB SSN COPAY SECONDARY INSURANCE CO. POLICY NUMBER GROUP NUMBER FORMS FORMS/SERVICE FEES Fees will be charged for the following forms if not requested at the time of an office visit: Blue Card - $5 Camp & Sports Physicals Forms - $10 School Medication Authorization Forms - $5 FMLA or Disability Forms - $15 Letters requested by patients - $5 (ALL FORM FEES WILL BE DUE AT THE TIME OF PICKUP.) Rush Form Fee: If a form is needed in less than 24hrs. the form fee will be doubled. SERVICES Nurse/Lab visits which are non-physician visits - $10 (Weight checks, immunization updates, allergy shots, and labs.) No-Show Appointments - $50 Minimum $22 charge for any after-hours physician call not related to an office visit PLEASE READ AND SIGN AUTHORIZATION AND ASSIGNMENT I (We), the undersigned, hereby agree to pay all amounts and charges hereafter incurred by me or members of my family for services rendered by this office. In the event of non- payment, either by insurance or by me, the balance due will increase and will include a monthly 1.5% finance charge and may include attorney and/or collection fees. Collection proceedings may result in permanent dismissal. I acknowledge and agree that Pediatric Associates of Madison, P.C. and any affiliates or vendor thereof, including collection or billing companies, may contact me by telephone or text message to any telephonic number I have provided to you, and any other telephone number associated with my account, including wireless or mobile telephone numbers. I further agree that you may use any method of contact to these numbers, such as an Automated Telephone Dialing System (ATDS) or prerecorded message. I also agree that I will notify Pediatric Associates of Madison, P.C. if I have given up ownership or control of any such telephone number. CONSENT FOR TREATMENT I authorize the doctors of Pediatric Associates of Madison, P.C., to treat my minor children listed above as they deem medically necessary. I authorize emergency medical treatment for the above-named child(ren) in the event that he/she is brought into this practice by any person other than myself. SIGNATURE OF PARENT OF LEGAL GUARDIAN PRINT NAME DATE
3 APPOINTMENTS We ask that you call to schedule appointments, as this is not a walk-in clinic. We strive to adhere to our office schedule as much as possible and request that you arrive for your appointments on time. Unfortunately, delays do occur. We attempt to remind all patients of pre-scheduled appointments. We will call the home number to remind; however, it is difficult for us to always be sure of confirmation by phone. Please do not depend on us to call and remind you. Please mark your calendars. We require a 3-hour notification for checkup cancellations. Failure to do so will result in a $50.00 missed appointment fee. Failure to show for any appointment will result in a $50.00 missed appointment fee. PRESCRIPTIONS Prescriptions and refills are issued during regular hours, Monday-Friday (8:00a.m-4:30p.m) Our nursing staff will call in prescription refills as time permits. Routine prescription refills should be requested no less than 24 hours prior to the date required. Please do not wait until your child s last dose of medicine to call for a refill. OFFICE HOURS/ EMERGENCIES Our office hours are Monday-Friday from 8:00a.m- 4:30p.m closed for lunch (12:15p.m-1:15p.m) We are closed on weekends and major holidays: New Years Day, Memorial Day, July 4 th, Labor Day, Thanksgiving Day, and Christmas Day. If you need emergency care at any time, please call 911 or go to the Pediatric E.R. at Women s and Children s Hospital or your nearest E.R. If you need urgent medical advice after hours please call (256) and the answering service will have the on-call physician return your call. We currently share weekend call with Twickenham Pediatrics and Hazel Green Pediatrics. Please remember to call during regular office hours for all non-urgent medical calls. TELEPHONE CALLS Our primary responsibility is to the patients who are in the office seeking medical care. Phone messages are returned by our nursing staff on a daily basis when time permits, based on the urgency of the call. When leaving a message, include telephone number(s) where you can be reached over the next several hours. WE RETURN CALLS FROM MULTIPLE OUTGOING PHONE LINES, SO YOUR CALLER I.D. MAY NOT DISPLAY OUR MAIN NUMBER; HOWEVER, INCOMING CALLS WILL ONLY BE RECEIVED ON OUR MAIN NUMBER (256) IF YOUR CHILD HAS A LIFE-THREATENING EMERGENCY, PLEASE CALL 911. Exciting new website: healthychildren.org This Children s Healthcare website is offered by the AAP and includes a symptom-based application to help parents determine the appropriate action to take: whether to treat a child at home or take him/her to the doctor or ER. It is the policy of Pediatric Associates of Madison physicians that your child(ren) receive all immunizations and checkups recommended by the AAP. Failure to comply with this recommendation will result in dismissal from our practice for noncompliance. GENERAL INFORMATION Immunization/Checkup Schedule 2 week 2 months 4 months 6 months 9 months 12 months 15 months 18 months 2 years 3 years 4 years and checkups every year thereafter. If your child needs a yearly physical, please schedule this visit during the spring or summer. Please schedule your next checkup when leaving the office. Yearly checkups are scheduled at least 3 months in advance. Immunizations and allergy shots are given on Tuesday, Wednesday, and Thursday from 9:00 a.m. to 11:30 a.m. and 1:30 p.m. to 4:00 p.m. with a nurse appointment. Service fees will be charged for the following: Physician calls that are not related to an office visit. Prior authorizations (phone or written) for medications-$5.00. Letters requested by patients to agencies- $5.00 per page. FMLA and disability forms-$ Sports physical forms-$ Medicine forms-$5.00 per form. Blue cards-$5.00 each. Rush fee-if forms are needed in less than 24 hours, the above fees will be doubled. If the above forms are completed at the office visit, there is no charge. A nurse fee of $10.00 is charged for the following services: Any nurse visit (weight check, immunizations, allergy shots, etc.). Lab draws (without same-day appointment). Medical Records for Second Copy: $5.00 search fee. $1.00 per page for the first 25 pages. $0.50 per page thereafter.
4 IMMUNIZATION POLICY It is the policy of all Pediatric Associates of Madison physicians that your child(ren) receive all immunizations required by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control and Prevention (CDC) or the American Academy of Pediatrics (AAP). Immunization Schedule 2 and 4 months *Pediarix, HIB, Prevnar, and Rotateq 6 months Pediarix, Prevnar and Rotateq 12 months HIB, Prevnar and Hepatitis A 15 months MMR and Varivax 18 months DTaP 2 year Hepatitis A 4-5 years **Kinrix, MMR and Varivax years TdaP,Meningococcal and HPV *Pediarix includes DTaP, IPV, Hepatitis B *Kinrix includes DTaP, IPV The following immunizations are not currently required for school entry in the state of Alabama, but strongly recommended by the physicians of Pediatric Associates of Madison and the above organizations. Hepatitis B ( component in the Pediarix Immunization)- Required for TN Schools Rotavirus Hepatitis A Required for TN Schools Meningococcal HPV - 9 years of age and older, set of 3 vaccines. Flu vaccine is now recommended yearly, for ALL children age 6 months- 18 years of age. I acknowledge the receipt of the immunization policy of Pediatric Associates of Madison, and I agree to comply with the required immunizations. Parent/Guardian Date
5 Name DOB Today s Date BIRTH HISTORY: (please circle all that apply) vaginal caesarean Pre-term weeks full term weight breast bottle Complications: FAMILY HISTORY: (please circle all that apply) Diabetes Bleeding Problems Cancer Heart Disease Mental Illness High Cholesterol Seizures / Epilepsy Maternal Height Allergies Paternal Height PAST MEDICAL HISTORY: (please circle all that apply) Chickenpox Pneumonia Wheezing Seizure / Loss of consciousness Eczema Vision problems Broken bones Bedwetting Kidney / bladder problems Development / Behavior problems SURGICAL HISTORY: (please list all previous procedures) SOCIAL HISTORY: (please circle all that apply) Patient lives with: Mother Father Siblings Other: Pets smoke exposure Attends daycare / school Guns in home DAILY MEDICATIONS / HERBS / SUPPLEMENTS: (if so, please list)
6 Pediatric Associates of Madison 21 HUGHES RD. SUITE 2 MADISON, AL (256) FAX (256) AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Each Patient Must Have a Separate Release Form PLEASE PRINT CLEARLY DATE: Patient Name: Date of Birth: Street Address: City: State: Zip: Please Check One: Sending Records to Obtaining Records From Physician/ Facility Name: _ Street Address: City: State: Zip: Phone No: Fax No: Information to be sent or received: (check all that apply) Entire Record Immunizations X-Ray Reports Laboratory Reports Other Specify: A $10 RETRIEVAL FEE AND A FEE OF.50 PER PAGE WILL BE CHARGED FOR ANY RECORDS THAT HAS TO BE RETRIEVED FROM STORAGE. I hereby Release and Authorize Pediatric Associates of Madison, P.C. to Release the Medical Records of the dependent listed (or self 18 or over) including diagnosis, treatment, prognosis, and recommendation, as well as other data pertinent to patient s treatment to the following location listed above. I hereby state that I am the child s parent or court appointed legal guardian and have the legal right to make and/or restrict healthcare decisions regarding this child, and that my parental authority has not been terminated or restricted by the courts. I understand that is authorization will expire twelve months from the date signed. Signature Date Relationship to child:
7 PEDIATRIC ASSOCIATES OF MADISON RIGHT TO PRIVACY CHART# Patients Name Date of Birth We at Pediatric Associates of Madison respect your child s right to privacy. Therefore, our Providers and staff will only access and use your Protected Health Information (PHI) for treatment, payment, and healthcare operations such as: 1. To provide care here in our office 2. To collect payment from your insurance company. 3. To assist your pharmacy in filling prescriptions. 4. To coordinate care with specialists to whom your child was referred. 5. When a minor reaches the age of fourteen, we can no longer discuss the child s private medical information with a parent without the child present or a written consent from the child. The exception is as follows: if a child seeks medical treatment and wishes to use the parent s insurance policy, it is the policy holder s right to know what their insurance company has been billed for. If the child does not wish for the policy holder to be given that information, they must pay cash up front for that visit. All other releases of personal information will be authorized by a signature. THIS INCLUDES YOUR IMMEDIATE FAMILY UNLESS OTHERWISE DESIGNATED BELOW. In the event of an emergency, we will contact your designated emergency contact. I authorize the staff of Pediatric Associates of Madison to discuss my child s care with the following persons: Relation Relation Relation I understand and consent to the use of my protected health information for the above purposes. Signature Date:
Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)
PEDIATRIC ASSOCIATES OF MADISON 21 Hughes Rd., Suite 2 Madison, Alabama 35758 256-772-2037 Fax 256-772-9523 www.pedsofmadison.com Tonya T. Zbell, M.D. Robbie F. Dudley, M.D. Charlotte M. Meadows, M.D.
More informationWelcome! 2128 Spears Rd, Suite 300 Houston, TX 77067~ Fax: ~ Rev 3/20/14
Welcome! Welcome to Premier Pediatrics of Houston! We are very excited that you have chosen us, and we are confident that you will be very pleased with the service and care we provide to your family. Please
More informationPEDIATRIC 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 informationPediatric 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 informationPATIENT S NAME: LAST NAME: FIRST NAME: MI: DOB: MARRIED: SINGLE: SOCIAL SECURITY: HOME ADDRESS: APT# CITY: STATE: ZIP: CELLULAR PHONE:
5056 THOROUGHBRED LANE BRENTWOOD, TN 37027 TODAY S DATE: PHONE: 615-373-3337 FAX: 615-373-3782 PATIENT S NAME: DATE OF BIRTH: M F RESPONSIBLE PARTY/GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: DOB:
More informationPrint 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 information12057 Jefferson Blvd LA, CA (323)
Playa Vista Mental Health General Adult and Women s Psychiatry 12057 Jefferson Blvd LA, CA 90230 (323) 813-6218 Please read and complete each of the sections listed below as completely as possible. NEW
More informationOffice 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 informationPage 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 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 informationINSURANCE 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 informationLAST 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 information12086 Ft. Caroline Road, Suite #401, Jacksonville, FL Phone: (904) Fax: (904) Patient Full Legal Name Date
12086 Ft. Caroline Road, Suite #401, Jacksonville, FL 32225 Phone: (904) 565-1271 Fax: (904) 645-7325 James A. Joyner, IV, MD, Kia M. Mitchell, MD, Thanh Nguyen, MD Dewey Lee, III, PA, Linda Rowan-Vander
More informationPATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD
PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD General Consent for Treatment I have the legal right to consent to medical and surgical treatment because (a) I am the patient
More informationMAIN 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 informationMedical History Form
Medical History Form Patient Name of Birth Medical History Do you have or have you had any of the following? Condition Yes No Condition Yes No Condition Yes No ADHD Stroke Menopausal Syndrome Allergies
More informationDevelopmental Pediatrics of Central Jersey
PATIENT INFORMATION: CLIENT INFORMATION Date: Name: (Last) (First) (M.I.) Birthdate: Sex: Race: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email Address: Regarding the office staff or physician
More informationMobile Mammo Registration Instructions
Mobile Mammo Registration Instructions 1. Call to schedule your appointment @ 239-936-4068 2. Fill out the following forms Note: All forms must be completed even if you were a previous patient on RRC Mobile
More informationNEW 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
More informationPlease be sure to bring your insurance card(s) and required co-payment (if any) to the appointment.
118 Oakmont Drive Greenville, NC 27858 252.364.8790 www.piratepediatrics.com Welcome to Pirate Pediatrics! We are here to provide you and your child with quality and compassionate care. We see children
More informationThank you for choosing Oakland Medical Center as your Patient-Centered Medical Home
Thank you for choosing Oakland Medical Center as your Patient-Centered Medical Home We ask that you complete the enclosed paperwork and bring it with you at the time of your appointment. We also ask that
More informationNAME 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 informationSocial 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**IF YOU SHOW UP WITHOUT ANY OF THE LISTED ITEMS, WE WILL RESCHEDULE!!!**
Dr. Jasna Kojic 6000 Turkey Lake Rd. Suite 205 Orlando, FL 32819 PHONE: (407) 649-1848 FAX: (407) 649-1979 Dear Parent/Guardian of : We welcome you and your son/daughter to our office and are happy to
More informationPediatrics How-to Guide for TRICARE Beneficiaries. Readiness Better Care Trusted Care, Anywhere Best Value Better Health
Pediatrics How-to Guide for TRICARE Beneficiaries Pediatric Clinic Operations How to Set Up an Appointment Appointment Line 722-1802 (0700-1630) Call early for same day appointment! 1. The Appointment
More informationAdult 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 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 informationHow did you hear about us? (please circle one)
REGISTRATION Client Information Office Use Only Client #:... Last Name First Name Driver s license # Street Address (DO NOT USE PO BOX ADDRESS).... City State Zip Code ( ) -. ( ) -. ( ) -. Home Phone #
More informationADMISSION INFORMATION
Texas Dept of Family and Protective Services ADMISSION INFORMATION Form 2935 Aug 2010 / Pg 1 of 3 Operation Name The Stepping Stone Director s Name Ashley Stock Child s Full Name Child s of Birth Child
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 informationTo 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 informationPatient Information Form
Patient Information Form Full Name: Date of Birth: / / Gender: M or F SS#: Marital Status: Single Married Widowed Divorced Employment Status: Employed Unemployed Retired Disabled Address: City: State:
More informationWHY THIS FORM IS IMPORTANT
Pediatric History Form Age 17 and under WHY THIS FORM IS IMPORTANT As a full spectrum Chiropractic office, we focus on your ability to be healthy. Our goals are, first, to address the issues that brought
More informationCORAZON PANES SANCHEZ., M.D., L.L.C.
PERRYVILLE, MD 21903 Rising sun, MD 21911 BALTIMORE, MD 21221 PATIENT REGISTRATION NAME: DOB: SEX: ( ) MALE ( ) FEMALE SOCIAL SECURITY #: - - ADDRESS: CITY/STATE: ZIP:_ TELEPHONE #: MOTHER S NAME: FATHER
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 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 informationResponsible 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 informationPediatric New Patient Intake Form
Name: DOB: Page 1 of 5 Pediatric New Patient Intake Form Patient Information Last Name: First Name: DOB: Home Mobile Preferred (circle) : Home / Cell Email: Gender: Primary Pediatrician: Pediatrician Address:
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 informationFrom: AR Center (Arkansas Center for the Study of Integrative Medicine)! PLEASE READ FIRST!!
From: AR Center (Arkansas Center for the Study of Integrative Medicine) PLEASE READ FIRST Please be sure that you have a QUALIFYING MEDICAL CONDITION for Medical Marijuana in Arkansas. If you do not have
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 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 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 Demographic Sheet Chart # (clinic use only)
Patient Demographic Sheet Chart # (clinic use only) Date: Annual Verification/Date/initials Best Contact Number to Reach You: Patient Information: Please List All Children in the Family Last First Middle
More informationAGE Is the student age 18 or older? (If YES, please skip to signature section below) p YES p NO
New York Summer music FeStivaL PERMISSION FORM This form must be emailed or faxed to NYSMF before your arrival. StudentName _ Festival Year AGE Is the student age 18 or older? (If YES, please skip to signature
More informationPlease allow us hours to refill the medication; approval from your medical provider is required on all refills.
Thank you for choosing Rex Primary Care of Holly Springs for your primary care needs. To keep our patients better informed we have created a list of our office policies to make your visit and continuation
More informationWabash Student Health Center
Wabash Student Health Center Information and Instructions for Completing the Student Health Record Dear Incoming Wabash Student: Welcome to Wabash College! In order to make your experience at Wabash a
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 informationLangston University Returning Athlete Screening Form
Langston University Returning Athlete Screening Form Name: Address: Social Security #: : Phone: Sport: DOB: M / D / Y 1. Have you had any injury since your last athletic screening here? Yes: No: If yes,
More informationWelcome to BCHC Your Medical Home
START HERE 1 Welcome to BCHC Your Medical Home Thank you for choosing Berks Community Health Center (BCHC) as your medical home. This booklet gives you information about being a patient at BCHC and what
More informationWelcome 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 informationPatient: 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 informationStaci F. Condrey, MD Robert D. Roycroft, MD Samantha Lane, DO
6 Years 17 Years Old Staci F. Condrey, MD Robert D. Roycroft, MD Samantha Lane, DO Welcome to Weddington Internal Medicine & Pediatrics, an affiliate of Carolinas Healthcare System! You have scheduled
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 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 informationPATIENT 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(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 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 informationAmarillo 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 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 informationNEW PATIENT INFORMATION: ADULT
NEW PATIENT INFORMATION: ADULT Patient Last Name: Patient First Name: Patient Middle Name: DOB: Sex: M F SSN: Address: City: Zip: Home Phone: Cell Phone: Email: EMERGENCY CONTACT INFORMATION Last Name:
More informationWILMINGTON 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 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 information714 Beacon Street, Newton Centre, MA,
Nancy Cooper, MD Kari Emsbo, MD Yana Urman, MD 714 Beacon Street Newton Centre, MA 02459 617-332-1001 Phone 617-332-5154 Fax Dear Patient: On behalf of all of us at Beth Israel Deaconess HealthCare-Newton
More informationKent 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 informationResponsible 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 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 informationat with. (Date) (Time) (Physician)
Dear Lombardi Patient: Georgetown University Hospital s physicians and staff would like to welcome you and thank you for choosing the Lombardi Comprehensive Cancer Center for your care. Our goal is to
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 informationWelcome 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 informationCommunity Life Center
Community Life Center- 2018-2019 Page 2 of 6 MEGA SPORTS CAMP- Waiver & Release Forms Effective Dates: January 1, 2018 January 1, 2019 CHILD S INFORMATION Name Grade Age DOB Male/Female Nickname School:
More informationPLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE (MR: )
PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE DATE: (MR: ) Office Use Only PATIENT S NAME: (FIRST, MIDDLE INITIAL, LAST) DATE OF BIRTH AGE SOCIAL SECURITY # MALE/FEMALE ADDRESS
More informationRETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria
RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, 2015 Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria February, 2015 Dear Parents: After several years of 7 th graders
More information9129 Dickey Drive Mechanicsville, VA 23116
WELCOME TO STOVER CHIROPRACTIC, P.C. Congratulations on your decision to join the millions of people who are enhancing their lives through regular chiropractic care. We, at, welcome you and will strive
More informationNORTH COUNTY PHYSICAL THERAPY, INC. DBA MISSION PHYSICAL THERAPY GROUP
NORTH COUNTY PHYSICAL THERAPY, INC. DBA MISSION PHYSICAL THERAPY GROUP Last Name First Name MI Mailing Address City State Zip Date of Birth Age SSN: - - Gender: M or F Home Phone Cell Phone Email: Patient
More informationINSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE
INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE All families are required to complete and submit ALL pages of this Health Form Package for their student
More informationPatient Registration Form
Date: Padma Sripada MD, Columbia Internal Medicine 2500 Pond View, Suite 202 Castleton on Hudson, NY 12033 Phone: 518-391-2889 Patient Registration Form First Name Middle Last Name... Sex: M F Date of
More informationParma High School Washington, DC Trip 2018
Parma High School Washington, DC Trip 2018 Dear Parents: Please find the attached Parents Approval Form Educational Trips Overnight / Out-of-State / Out-of-the-Country. Parents are asked to neatly print
More information*A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR TO ADMITTANCE*
WASHINGTON ACADEMY STUDENT HEALTH INFORMATION PACKET SCHOOL NURSE: PHONE: 973-239-6555 Ext: 204 FAX: 973-239-6335 *A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR
More information*** Program Guidelines ***
*** Program Guidelines *** *The Junior Volunteer program has a limited number of available positions. Placement decisions will be based upon first come, first serve. Volunteers must be at least 15 years
More informationHospital Name. Medical Record Number: Hours/Days of Operation: Clinic: Physician: Contact Person / Title: Phone: Fax: Hours/Days of Operation:
Hospital Name City, State, Zip Code: Phone Numbers: Main Number: Emergency Room: Medical Record Number: Clinic: Hours/Days of Operation: Physician: Contact Person / Title: Phone: Fax: Email: Clinic: Hours/Days
More information2017 VolunTEEN Scheduling Form. SHIRT SIZE: S M L XL XXL **sizes run big
2017 VolunTEEN Scheduling Form NAME: PHONE #: SHIRT SIZE: S M L XL XXL **sizes run big Indicate below your preference of shift by numbering the blocks by 1 st, 2 nd and 3 rd choice. If you have two first
More informationAllergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease
Allergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease Arthur Fost, M.D. David Fost, M.D. Satya Narisety, M.D. Anthony J. Piccolo, PA-C Patient s Name
More informationInland Empire Region phone fax. CAIR v 3.30 Data Entry Guide Rev 4/09
Inland Empire Region CAIR v 3.30 Data Entry Guide Rev 4/09 Riverside County Department of Public Health A partnership between San Bernardino County Department of Public Health Help Desk 1-866-434-8774
More informationThe office requires that you provide 24-hour notice to cancel or reschedule appointments.
Before your first Allergy/Asthma appointment: Please verify that Baker Allergy, Asthma, and Dermatology is in network with your insurance plan before your appointment date. If needed, obtain a referral
More informationA copy of the birth certificate or proof of birth letter from the hospital. Your support in this matter is greatly appreciated.
Attention Parents We are required by the Commonwealth of Virginia to secure, before the child may attend, and maintain, while in our care, a current file containing specific information regarding the health
More informationST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient
More informationVaccine and International Travel Health Questionnaire Please print clearly.
Vaccine and International Travel Health Questionnaire Please print clearly. Name: Age: DOB: Sex: M F Last Name First Name MI MM/DD/YYYY Home Address: Street Address City State Zip Phone: Home/Cell Email:
More informationHome Address City State Zip. ( ) Parent/Guardian First Name Last Name Home Phone Number. Home Address City State Zip ( ) Cell ( )
GREENKNOLL SCHOOL AGE CHILD CARE 2018-2019 School Year Fees due at the time of registration: $25 Registration Fee + First Week s Tuition Weekly tuition rates listed on payment sheet Child s First Name
More informationPulmonary Intake Form
Pulmonary Intake Form Name DOB Date Please list the referring physician or other physicians that you would like this office visit to be shared with. Pharmacy Name, Location, and Phone Number Reason for
More informationLONE STAR COLLEGE-TOMBALL DOCUMENTATION OF REQUIRED IMMUNIZATIONS Please Print
LONE STAR COLLEGE-TOMBALL DOCUMENTATION OF REQUIRED IMMUNIZATIONS Please Print Name: (Last) (First) (MI) of Birth ID# Enrollment All students enrolled in health related courses who have or will have any
More informationPatient Registration Form Pediatrics
Patient Registration Form Pediatrics For Office Use Only: Visit Date: Initials: PATIENT INFORMATION Preferred Language: English Spanish Other: Patient s Last Name First Middle Initial Date of Birth Sex
More informationTHERAPY ATTENDANCE POLICY
! THERAPY ATTENDANCE POLICY The primary focus of Dynamic Strides Therapy, Inc. s ( DST ) therapy program (the Program ) is to help the Patient named below to achieve his/her goals for therapy. We strive
More informationPATIENT'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 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 informationChoptank Community Health System Caroline County School Based Health Centers Healthy Children Are Better Learners MEDICAL
Choptank Community Health System Caroline County School Based Health Centers Healthy Children Are Better Learners MEDICAL Dear Parent/Guardian: As a student in the Caroline County Public School system,
More informationREGISTRATION FORM (Minors)
LEGAL NAME REGISTRATION FORM (Minors) Social Security#: Date of Birth: Sex: M or F Nickname: Religion: Church: Race (circle one): White Black-Asian AM Indian Alaska Native Native Hawaiian Pacific Islander-Unknown
More informationALFRED 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 informationMedications 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 informationSTUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16*
STUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16* CONTACT INFORMATION Name: Date: Address: Home Phone: Cell Phone: Email: Over 16? Over 18? EMERGENCY CONTACT INFORMATION Emergency Contact:
More information