NEW PATIENT APPTS. Here are a few words about Our Doctor and his Medical Practice:
|
|
- Giles Doyle
- 5 years ago
- Views:
Transcription
1 ...your health is Our Story NEW PATIENT APPTS Here are a few words about Our Doctor and his Medical Practice: At Our Office, we strive to bring back the personal experience of having an Old-Fashioned Family Physician. As a Medical Practice, Story Family Medicine is fully dedicated and designed to provide our patients with Complete Medical Care, Coordination and the best Community Resources available. * Dr. Story takes his own office phone calls directly, after hours and on the weekends, in case of an emergency. Our office keeps appointments available for urgent visits, if needed, as well as scheduled follow ups for routine care. * Dr. Story is credentialed at Fawcett Memorial Hospital and handles his own hospital admissions. This prevents unnecessary testing and helps decrease hospital stays since your current condition and medical history is reviewed by your Family Physician. Once discharged, our office provides coordination with transitional care and home-based medical services. A few reminders regarding your New Patient Appointment: Please arrive minutes before your appointment time, for processing your paperwork. If your paperwork is not completed by your appointment time, your appointment will have to be re-scheduled. Complete all sections of Paperwork including your Medical, Family and Surgical History, etc. Provide a copy of a Photo ID, Insurance Card and Prescription Drug Card (if applicable) If you need to cancel or reschedule your appointment, please do so within 24 hours, if possible. We try to accommodate urgent visits, walks in and other care coordination activities. This is greatly appreciated. We have a big family. Thank you for your interest in Story Family Medicine. Our Office Location: Toledo Blade Blvd Suite A Port Charlotte FL Main Tele: Fax:
2 STORY FAMILY MEDICINE NEW PATIENT REGISTRATION Health and Social History Have you ever smoked/used tobacco products? Yes No (If Former smoker, when did you Quit?) Do you currently smoke? Yes No (If you currently smoke, how many a day or week?) Do you drink alcohol? Yes No (If yes, how often): Currently use recreational drugs? Yes No Do exercise regularly? Yes No (If yes, how often): What type of exercise? Nutritional Diets: Diabetic Diet Low Sodium Low Fat Low Cholesterol Other: Do you have drug, environment or food allergies? Yes No(If yes, please list type and reactions) Do you currently work? Yes No Are you Retired? Yes No Are you currently Disabled? Yes No Major Events and History No Today's Date: _ Name: Date of Birth: / / Height: Last First Status: Married Single Widowed Child Other Gender: Female Male Gender Re-Assignment Social Security: (For Billing Purposes) Religion: Ethnicity: Phone (Home) Cell Work (if applicable) Address: (Required for Online Medical Records) Address: Is this a seasonal residence? Yes No City State Zip In Case of an Emergency Name: _Relation Spouse Mother Father Grandparent Friend Other: Phone: Is it okay to contact this person in case of an emergency? Yes No Advanced Care Directives, Medical Wishes or Other Preferences *Do you have a living will? Yes No n/a *Are you an organ donor? Yes No n/a *Do you have a DNR? Yes No n/a *Do you have a Power of Attorney? Yes If you have a Power of Attorney or a Health Care Surrogate, please list them below. Name: Relationship Phone Number Are we able to disclose Medical Information with them? YES No Health Insurance Information Do you have Health Insurance? Yes No (Relationship to Insured) Self Dependant Primary Insurance Policy# Plan Type HMO PPO Medicare Federal Veteran Disability Other Secondary Plan: Policy# Is this a Medicare Plan? Yes No Do you have Medicaid? Yes No (Please Advise: We are Out-of Network with Medicaid) Complications to Medical Treatments Yes No Hospital Admissions or Emergency Care? Yes No OTHER PROVIDERS/ SPECIALISTS PAST SURGERIES/OPERATIONS LIST OF PREFERENCES Provider Name Specialty Type Type of Operation Date Hospital Pharmacy Laboratory No other Providers Imaging Do you have any health concerns that need further clarification? Yes No (If yes, please explain) _ How did you hear about Dr. Story? 1
3 Current Medical Conditions Anemia Anxiety ADD/ADHD AIDS/HIV Asthma Blood Clots Blood Disease Blood Deficiency Cancer: Chronic Back Pain Congestive Heart Failure Colitis/IBS COPD Family History _ COPD CoronaryAtherosclerosis _ Depression _ Diabetes _ Fibromyalgia _ Erectile Dysfunction _ Headaches _ Hypertension _ Hypothyroid _ High Cholesterol _ Heart Disease _Heart Attack _ Heart Arrhythmia Mother Father Sibling Other Heart Issues Heart Attack Stroke Alcoholism Breast Cancer Colon Cancer Other Cancer Depression Diabetes Thyroid Issues List of Current Medications Dates of Procedures or Testing Diagnostic Tests: Colonoscopy: Bone Density: Mammogram: Chest Xray: EKG: Echo: Stress Test: Other: Immunizations: Pneumonia 23: Pneumonia 13 Booster: Flu Vaccine: TDap/Tetanus: Shingles Vaccine: Review of Symptoms or New Complaints Eyes: _ Blurred Vision _ Double Vision _ Eye Pain _ Worsening Sight Ears & Hearing: _ Hearing Loss _ Ringing in Ears _ Wax Buildup Head & Neck: _ Headaches _ Dizziness _ Lightheaded _ Memory Loss GI: _ Difficulty Swallowing _ Nausea/ Vomiting _ Stomach Pain _ Loss of Appetite _ Diarrhea _ Constipation Urinary: _ Burning _ Frequent Urination _ Difficulty Urinating _ Incontinence _ Hesitancy Oral: _ Dry Mouth _ Loss of Taste Nose & Throat: _ Sneezing _ Nose Bleeds _ Runny Nose _ Sinus Issues _ Sore Throat Respiratory: _ Asthma _ Cough _ Shortness of Breath _ Wheezing Cardiac: Patient Name: Chest Pain _ High Blood Pressure _ Palpitations _ Irregular Heartbeat Kidney Stones Kidney Disease _ GERD Pacemaker Status _ GOUT Ulcers _ Glaucoma Unsteady Balance _ Gallbladder Disease Urinary Incontinence _ Hepatitis Seiures _ Lung Disease _ Stroke _ Muscle Weakness _ Other: Respiratory Problems _ Rheumatoid Arthritis Osteoporosis Osteopenia No Medical History (Please specify type of Cancer) No Family History Unknown Family History No Current Medications Exams: Last Labs: Health Physical: Breast Exam: Prostate Exam: Muscle/Bones/Joints: _ Back Pain _ Sore/Achy Muscles _ Swollen Joints _ Painful Joints _ Foot Pain _ GOUT _ Leg Pain Neurological: _ Confusion _ Dizziness _ Seizures _ Numbness _ Tingling _ Tremors/Shaking _ Poor Balance _ Poor Coordination No Testing Completed No Current Complaints Skin: Pap Smear: Eye Exam: Foot Exam: Other: Rash/Hives _ Itching _ Bruising _ Abnormal Growth General Mood: _ Anxiety _ Depression _ Stressors _ Mood Changes
4 HIPPA Consent and SFM Policy Agreement Patient Name: Cancellation and No-Show Policy Office Visits when made are reserved for you alone. When you make an appointment, please make sure that you are able to keep it. Emergencies or unforeseen occurrences befall us all. Situations or problems may arise that cause schedule conflicts and other delays. If you have an unexpected medical issue that needs attention, we will do our best to accommodate you. We realize that other patients may be slightly inconvenienced, will understand the nature of a emergency situation. At some point, they may need the same courtesy too and we will be there for them as well! If you cannot keep your appointment, please notify us as soon as possible. We also like to accommodate walk-ins and have a waiting list of other patients that are also in need of appointments. Please contact us to cancel your appointment with-in 24 hours, if possible. There will be a charge of $30.00 per appointment that resulted in a no-show after the 3 rd time.. I acknowledge and understand the Story Family Medicine (Cancellation and No-Show Policy). PATIENT INITIALS: HIPPA-Consent to Treat and Disclosure of Health Information To Provide Treatment: We will use your HPI within the office to provide you medical care. This may include administrative, clinical and office procedures designed to optimize scheduling/coordination of care between the physician and/or other clinical, lab, imaging centers, pharmacies, or other health care providers handling your care. To Obtain Payment: We will use your HPI with an invoice, used to collect payment for the treatment you receive here. HPI will be used on your insurance forms sent by mail or electronically. In Patient Reminders: Phone calls to remind you of a upcoming appointment or situations will be necessary. Additionally, we may also use electronic methods to contact you such as , text message, by phone, online patient accounts, postcards, letters, statements, etc. These methods of communications help optimize our office workflow. Abuse of Neglect: We may notify government or other agencies if we believe a patient is a victim of abuse, neglect, or domestic violence. We will make their disclosure only when we are compelled by our ethic judgement, specially required, authorized by law or with patient s agreement and request. Public Health/National Security: We may be required to disclose to federal/ military officials or other authorities, if HPI is necessary to complete an investigation related to public health or national security. HPI is important to the government if they believe that public safety could benefit from, control or prevent an epidemic. For Law Enforcement: As permitted/required by State/Federal Law, disclosure of HPI may be necessary under certain circumstances, if warranted. Whether being a victim of a crime or reporting a crime. We will revoke access, at any time to also protect the patient, unless there is a warrant in place or consent given from the patient directly. I understand the Story Family Medicine (HIPPA Consent to Treat and Disclosure of Health Information) PATIENT INITIALS: Medical Health Benefits and Patient Responsibly/ Financial Policy IF YOU HAVE HEALTH INSURANCE As a condition of services by our office, a financial arrangement must be made. If you have Health Insurance, you are responsible with becoming familiar with what coverage and financial responsibility you have. Your insurance benefits are a contract between (you and your insurance company). To file claims properly, you must present us a copy of active insurance cards. Services rendered, will be charged directly to your account for any balance owed/pending review/response with the insurance regarding your reimbursement/benefit. Any balances transferred to the patient s responsibility must be paid within a timely manner. There is a $25.00 fee for returned checks. Any fees due at the time of service include: Co-pays, deductibles, non-covered services or patients that are not covered by insurance. IF YOU DO NOT HAVE HEALTH INSURANCE For self-pay patients, we offer discounted rates, though we require payment in full at the time of their office visit. We accept Cash, Visa, Mastercard, Visa, American Express and Discover. I acknowledge and understand the (Medical Health Benefit and Patient Responsibility/ Financial Policy) and accept financial responsibility for my medical care provided by Story Family Medicine. PATIENT INITIALS: Narcotic Prescribing and Medication Adherence Policy Scheduling an appointment, does not guarantee that you will be prescribed Narcotic or other types of medications. Some medications may provide therapeutic relief, though many have more risks than benefits, and may cause harm if used incorrectly. Certain measures must be taken to ensure the patient s safety before prescribing can be done. The patient must disclose all medications that they are currently taking or any illicit drugs being used. Narcotic medications WILL NOT be prescribed at the New Patient Appointment. No exceptions. If there are medications that are medically necessary, blood work and a urine drug screening must be completed before the next appointment. We will also require Medical Records from the former prescribing doctor that managed your medication so we can transition your care properly. I acknowledge and understand the (Narcotic Prescribing/Medication Adherence Policy), I agree to the terms as stated above. PATIENT INITIALS: To the best of my knowledge, all of the preceding answers and information provided are true and correct. I accept the conditions outlined above have read the Office Policies of Story Family Medicine. Signature of patient, parent of guardian or guarantor Date 3
5 1) PATIENT INFORMATION: Name Address City State Zipcode ( ) Date o fb irth Daytime P hone Previous Name 2) PATIENT AUTHORIZES (HEALTHCARE PROVIDER/FACILITY): Name of Healthcare Provider or Agency Address 3) TO DISCLOSE TO: MEDICAL RECORD RELEASE URGENT REQUEST YES NO Date Needed by: Dr. Curtis Story MD of Story Family Medicine Name of Healthcare Provider Health Care Provider Ph# Toledo Blade Blvd Suite A Port Charlotte, FL Address Fax# DELIVERY OPTIONS: Self Pick up Fax Mail to address above To be picked up by, I hereby authorize: (Photo ID required) 4) DATE(S) OF INFORMATION TO BE DISCLOSED: From to (If left blank, information from the past (2) years will be disclosed) (month/year) (month/year) 5) INFORMATION TO BE DISCLOSED: All medical records related to (specify condition, treatment, etc.): All billing records related to (specify condition, treatment, etc.): Radiology films/images (specify test): Specific records/information as follows: I DO NOT WANT THE FOLLOWING INFORMATION DISCLOSED (as defined by applicable state and federal laws): Alcohol/Drug Abuse HIV Test Results Mental Health / Developmental Disabilities 6) EXPIRATION: This Authorization is good until the following date / event: Note: If this item is left blank, the authorization will expire in one (1) year from the date signed. 7) PURPOSE (Check all that apply - copy fees may apply) Further Medical Care Legal Investigation /Action Insurance Eligibility/Benefits Personal (at my request) Other: 8) YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION: I am aware that I have the right to inspect and receive a copy of the health information I have authorized to be used and/or disclosed by this Authorization. I understand that I may be charged a fee for record copies. In addition, I understand that I do not need to sign this Authorization in order to receive treatment. I also am aware that I may revoke this Authorization by notifying the disclosing medical records/health information department in writing. However, I understand that my revocation will not be effective as to uses and/or disclosures: (1) already made in reliance upon this Authorization; or (2) needed for an insurer to contest a claim/policy as authorized by law if signing the Authorization was a condition to obtaining insurance coverage. I realize that the information used and/or disclosed pursuant to this Authorization may be subject to re-disclosure and no longer protected by federal privacy law. If you have issues receiving your records or information or need assistance in filing a civil rights or health information privacy complaint, please OCR at OCRMail@hhs.gov or call for more information. 9) SIGNATURE OF PATIENT / LEGAL REP: DATE: If signed by a person other than the patient, complete the following: 1. Individual is: a minor legally incompetent or incapacitated deceased 2. Legal authority: parent* legal guardian next of kin / executor of deceased activated POA for Health Care * By signing above, I hereby declare that I have not been denied physical placement of this child. For Office Use Only: Signature/ID verified Yes No Completed by: # of pages Name / Date released Fax # AUTHORI ZATION FOR DISCLOSURE OF HEALTH INFORMATION (Pre Tab / Corres) PRACTICE LOCATION Toledo Blade Blvd Suite A Port Charlotte, FL tele: fax: Health Care Provider Ph# 4
Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address
Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In
More 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 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 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 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 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 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 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 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 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 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 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 INFORMATION Name: Date of Birth Address: City: State: Zip
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single
More 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 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 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 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 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 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 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 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 informationPlease complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
More 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 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 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 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 informationWelcome to our office! Please fill out this form as completely as possible and return it to the desk.
Welcome to our office! Please fill out this form as completely as possible and return it to the desk. Name of Doctor you wish to see: Today's Date Name Email Address Address Home Male Female Cell City
More informationPlease complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
More 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 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 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 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 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 informationEmergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:
New Patient Office Information Last Name: First Name: Initial Date of Birth: SSN # Marital Status: Single Married Divorced Widowed Address: City: State: Zip: Gender: M Parent/ Legal Guardian if Patient
More informationAge: Birthdate: Date of Last Physical exam:
Name: : Age: Birthdate: of Last Physical exam: SYMPTOMS: Check symptoms you currently have OR have had within the past YEAR. General Fever Chills Weight loss Weight Gain Headache Depression Vertigo Ringing
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 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 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 informationThe Providers and Staff of Baptist Medical Group Primary Care- LiveOak BAPTISTMEDICALGROUP.ORG. Primary Care - Live Oak.
BAPTISTMEDICALGROUP.ORG Primary Care - Live Oak Dear Patient, Thank you for choosing Baptist Medical Group Primary Care - Live Oak to provide you with compassionate care for your health care needs. We
More informationNew Patient Registration Form. Male Female
New Patient Registration Form Today s Date Last Name Nickname Home Address DOB / / First Name Male Female City State Zip Code Email Medical Power of Attorney (if applicable) DOB / / Address City State
More informationPatient Communication Request
Patient Communication Request Name: Date of Birth: Address: ZIP: Home Phone: Work Phone: Cell Phone: E-mail address: It is the policy of Capstone Family Practice to contact patients for any lab results.
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 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 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 informationYour annual preventive visit, or complete physical exam, is scheduled with. Dr. on at AM/PM.
Dear: Your annual preventive visit, or complete physical exam, is scheduled with Dr. on at AM/PM. Please bring the following with you on the date of your appointment: A list of your current medication(s),
More informationTOS Health Questionnaire
Name Referring Physician Main Reason for Medical Evaluation of Injury/Length of symptoms: Is this a work related problem? Y N Are you right or left handed? Occupation What treatment have you received for
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 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: 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 informationSeasons Women s Care Patient Registration Form
Seasons Women s Care Patient Registration Form Name: of Birth: Address: City: St: Zip Home Phone: Cell: Best Number: Email: Race or Ethnicity: Marital Status: SS# Drivers Lic#: Employer: Work# Occupation:
More 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 informationSurgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL
Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL 32789 407-647-1331 Name Date Email @ Please Circle One: Ethnicity: Hispanic or Latino American/White Not Hispanic or Latino Unknown
More 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 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 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 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 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 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 informationNorman H. Anderson M.D., P.A. Robert Boissoneault Oncology Institute INSURANCE AUTHORIZATION
Norman H. Anderson M.D., P.A. D/B/A Robert Boissoneault Oncology Institute 2020 SE 17 th Street Ocala, Fl 34471 522 N. Lecanto Highway Lecanto, FL 34461 605 W. Highland Blvd. Inverness, FL 34452 9401 SW
More informationRenée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD
Renée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD RHEUMATOLOGY CONSUTLATION ARTHRITIC CONDITIONS AUTOIMMUNE DISEASES MUSCULOSKELETAL ULTRASOUND Name: First Name Last Name Social Security Number: Sex:
More informationCity. Whom may we thank for referring you to us?
CAMBRIDGE DENTAL CENTER - PATIENT REGISTRATION Date Patient's Last Name First :Kame MI Age Soc. Sec. No.: Home Work Phone: Home rujul
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 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 informationACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION
Patient Name (PLEASE PRINT): Date of Birth: ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION The & Center of Southern Oregon, PC s Notice of Privacy Practices contains information about the uses and disclosures
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 informationPatient Name: Last First Middle
Wilmington Ear Nose & Throat Associates, PA Patient Information Form Patient Name: Last First Middle Mailing Address: Street Address (if different from above): City: State: Zip Code: Social Security #:
More informationPlease bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address
More 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 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 informationM or F Patient s Date of Birth Patient s Social Security Number Sex. Secondary Address: (if have, Northern) Street City State Zip Code
PATIENT REGISTRATION PLEASE PRINT Today's Date: Referred by: Patient s Name: Last First M.I. M or F Patient s Date of Birth Patient s Social Security Number Sex Primary Address: Street Apt/Unit # City
More 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 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 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 informationMay 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 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 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 informationDate: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?
Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic
More informationR. B. KO L A C H A L A M M. D. GENERAL SURGERY
GENERAL SURGERY Patient Information (Please Print and Circle or check the appropriate response) Patient s Name: DOB: _ Address: City: _ Zip: Home Phone: Cell: Work:_ Email Address: Patient s SSN: Male
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 informationNEW PATIENT INFORMATION Primary Care Physician
Last Name NEW PATIENT INFORMATION Primary Care Physician Date: First Name MI Referring Provider Previous Name Date of Birth (mm/dd/yyyy) Address City Gender Male Female Marital Status Single Divorced Married
More informationDate: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?
Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic
More 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 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 informationWELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT You are scheduled to have an appointment at the UPMC Liver Cancer Center which is located in the UPMC Montefiore
More informationVirginia Heartburn & Hernia Institute
Virginia Heartburn & Hernia Institute PATIENT INFORMATION FORM (Please make sure to print clearly and sign at the bottom of this page) Patient s Last Name: First: Middle Initial: Marital Status: Married
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 informationCURE CARDIOVASCULAR CONSULTANTS
NEW PATIENT PACKET There are six pages in this packet that will help us get a clearer picture of your medical history and physical health. Please note: SIGNATURES are required on pages 2, 4, and 6. Please
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 informationFaculty Group Practice Patient Demographic Form
Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Email address Patient Information Street Address City State Zip Home Phone SSN Date of Birth Gender Male Female Work Phone Cell Phone
More 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 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 HEALTH QUESTIONNAIRE
PATIENT HEALTH QUESTIONNAIRE Last Name: First Name: MI: Date of Birth: SS#: Address: City: St: Zip: Cell#: Home #: Work#: Which number is the best way to reach you? Cell Home Work Email Address: Preferred
More informationPATIENT REGISTRATION
PATIENT REGISTRATION Date: Patient Name Last First Middle Initial (Nickname) Home Address Street Apt# City State Zip ( ) Male ( ) Female Body part being evaluated Marital Status: ( ) Single ( ) Married
More informationFamily Medicine Division. Nyree Bryant DO George R. Davis DO
Family Medicine Division Nyree Bryant DO George R. Davis DO 11/12/17 Dear New Patient, Welcome to Florida Medical Clinic! We are happy that you have made our office your choice for your medical care needs.
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 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 informationMAIN STREET RADIOLOGY
MAIN STREET RADIOLOGY PATIENT REGISTRATION FORM **OFFICE USE ONLY** TODAY S DATE: MR#: LAST NAME: FIRST NAME: ADDRESS: APT: CITY: STATE: ZIP CODE: HOME PHONE #: ( ) - CELL PHONE#: ( ) - DATE OF BIRTH:
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 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 informationDENTON UROLOGY 2401 West Oak Street Ste. #102 Denton, Texas Phone: Fax:
DETO UROLOG 2401 West Oak Street Ste. #102 Denton, Texas 76201 Phone: 940-387-2241 Fax: 940-380-1374 Acknowledgment of Review of otice of Privacy Practices I have reviewed this office s otice of Privacy
More information