PATIENT'INFORMATION'!
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- Rolf Harris
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1 PATIENT'INFORMATION'! ' Referred By: Date: PharmacyName,PhoneLocation: LastName: FirstName: MiddleName: DateofBirth: Gender: SSN: MaritalStatus: DriversLicense: PrimaryLanguage: Race: _ AmericanIndian/AlaskaNative _ Asian _ Black/AfricanAmerican _ NatHawaiian/NativeIslander _White _ OtherRace _ Decline Ethnicity: _HispanicorLatino _NotHispanicorLatino _Decline Address: Apt# Zip: City: State:_ PreferredPrimaryPhone:( ) Type: Second:( ) Type: EmployerName: Occupation: EmergencyContact: Relationship: Phone:( ) Patient Portal _Yes Address: No INSURANCE'INFORMATION' ' PrimaryIns.Co: InsType:(Checkone)HMOPPOWCMVAEPOOTHER EffectiveDate: Policyholder: DOB: RelationshiptoPatient: ID#: Group#: PolicyholderSS#: PolicyholdersEmployer: Address: SecondaryIns.Co: InsType:(Checkone)HMOPPOWCMVAEPOOTHER EffectiveDate: Policyholder: DOB: RelationshiptoPatient: ID#: Group#: PolicyholderSS#: PolicyholdersEmployer: Address:! Assignment'of'Benefits,'Eligibility'Guarantee'and'Missed'Appointment'Policy' IrequestthatpaymentofauthorizedinsurancebenefitsbemadeonmybehalftoSanDiegoSportsMedicineandFamilyHealth Center(SDSMFHC)foranyservicesrendered.IauthorizeSDSMFHCtoreleasetomyinsuranceplananditsagentsany informationneededtodeterminethesebenefits.iherebycertifythatiameligiblefortheabovenamedhealthplanand,if applicable,havechosenaphysicianfromsdsmfhctobemyprimarycarephysician.iunderstandthatifiamnoteligibleunder thetermsofmyhealthplan,iamliableforallchargesforservicesrendered.ialsoagreetopayinfullforallnonxcovered serviceswithin30daysofnotificationofnonxcoverage.i authorize SDSMFHC to obtain information as needed from other medical providers and pharmacies in order to provide safe and comprehensive health care. IunderstandthatSDSMFHCwillchargea $25.00feeformissed appointmentsscheduledthatarenotcancelledwithatleast24hoursnotice. SignatureofPatientorParent/Guardian/Policyholder Date
2 AUTHORIZATION TO TREAT A MINOR For patients under age 18 In the event of a medical emergency, I authorize the physicians and staff of San Diego Sports Medicine and Family Health Center to provide necessary medical care to the patient named on the reverse side of this paper, if the parent/guardian is unable to be reached for authorization. I understand this authorization is revocable at any time by notifying San Diego Sports Medicine and Family Health Center in writing. Please sign below if you would like this authorization on file: Signature of Parent/Guardian Date. ADVANCE DIRECTIVES For patients age 18 and over A federal law requires us to give you information about your rights to make health care decisions. Your doctor must tell you about your medical condition and about what different treatments can do for you, and how you can plan what should be done when you cannot speak for yourself. In the event you become too sick to make medical decisions, it is helpful if you say in advance what you want to happen with your medical treatment. There are several kinds of advance directives that you can use to say what you want and who you want to speak for you. If you would like more information about advance directives, please notify your nurse or doctor. We have additional information to assist you in making these important decisions. Please sign below acknowledging the availability of information regarding Advance Directives. Signature of Patient over age 18 Date.
3 First and Last Name:_ DOB: / / Gender: Phone No.: Past Medical History (Please check any of the following that you presently have or had in the past and write the approximate date) Asthma Arthritis Allergies Anemia Alcoholism Cancer Colitis Depression Diabetes Epilepsy Fractures Headaches High Blood Pressure Heart Disease Kidney Problem Major Injuries Mental Illness Obesity Osteoporosis Strokes Thyroid Problem Tuberculosis Ulcers Other No pertinent history Past Surgical History (Please check all of the following surgeries you have had. For all surgeries, please enter date or surgery. If actual date is unknown, please put approximate date) Abdominal Arm Back Brain Breast Caesarian Cardiovascular Eye Finger Foot Hand Head Hip Hysterectomy Knee Leg Lung Neck Shoulder Vasectomy Other No Surgeries Current Medications (Please list all current medications, including dosage and how often you take it) Medication Allergies (Please list all current allergies to medications) No Medication Allergies Family Medical History (Please check any of the following that any of your relatives have or had. For Family History, please indicate which family member has this and which side of your family they are from. Include any applicable dates and ages) Asthma Arthritis Allergies Anemia Alcoholism Cancer Colitis Depression Diabetes Headaches High Blood Pressure Heart Disease Kidney Problem Mental Illness Obesity Osteoporosis Strokes Suicide Thyroid Problem Tuberculosis Ulcers Other (please continue on reverse) No Pertinent History
4 Reproductive History Age Menarche: Menses Duration: Last Menstrual Period: Menopause Status: Method of Birth Control: Age Menopause: Breakthrough Bleeding: Pregnancy Summary Total: Full Term: Premature: Abortion Induced: Abortion Spontaneous: Ectopic: Living: Birth History (Please enter your personal history or your child s birth history if filling out for your child) Full term(38-40 weeks): Vaginal or Caesarian: Infections during Pregnancy: Birth Weight: Gestational Diabetes: Stay in NICU: If Yes, Why: Hypertension During Pregnancy: Breast or Bottle Fed: Social History Current Diet: Education Level: Current Exercise: Home Environment: (Whom do you live with) Marital Status: Military History: Occupation: Parents Siblings: Sleep: Stress: Alcohol Use: Caffeine Use: Tobacco Use: Other Substance Abuse:
5 Acknowledgement of Receipt of Notice of Privacy Practices San Diego Sports Medicine and Family Health Center 6699 Alvarado Road, Suite 2100 and 2101, San Diego, CA Sorrento Valley Blvd., Suite 300, San Diego, CA Garnet Ave., San Diego, CA Privacy Officer: Office Manager, Phone No I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at future office visits as any amendments are made. Signed: Print Name: Date: Telephone: If not signed by the patient, please indicate: Relationship: parent or guardian of minor patient guardian or conservator of an incompetent patient beneficiary or personal representative of deceased patient Name of Patient: Methods of Communication Request I request the use of the following methods of communication of information related to my personal health, treatment or payment for treatment. I acknowledge that I am responsible for updating this information as necessary. This request supercedes any prior request for methods of communication I may have made. Please select all that apply. Where you list more than one communication option, please indicate which you prefer. Phone You may contact me by telephone at May we leave messages concerning results of laboratory work, other diagnostic testing, or referrals to other providers on your answering machine or with someone in your household? Yes No Do you wish for our physicians and staff to have detailed conversations concerning your health care and condition with family members or designated others? Yes No Name Relationship Name Relationship Mail (at the address provided on the registration paperwork) You may contact me at the following address: Fax You may contact me at the following fax number: (Not all physicians and/or staff have access to for the purposes of communicating with patients. By providing your address or fax number, you are authorizing our physicians and/or staff to communicate with you by or fax, the content of which may include protected health information. You agree that we are not responsible for the interception of those messages by others.) Signed: Date: Print Name:
Please 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: - -
LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W
PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS:
Please 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: - -
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Print 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:
PATIENT 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
PATIENT'REGISTRATION'FORM'FOR'KURT'R'WHARTON S'OFFICE' ' Last%Name:% %%%%%%%%%%%First%Name:% %%%%%%%%%%%%%%Middle:% %% % Responsible%Party:%
PATIENT'REGISTRATION'FORM'FOR'KURT'R'WHARTON S'OFFICE' ' LastName: FirstName: Middle: ResponsibleParty: Relationship: Address: Zip: City: State: PreferredPhone: Email: MaritalStatus: S M D W LegallySeparated
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Page 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:
Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:
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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
INSURANCE INFORMATION
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Dear Sir / Madam, You wish to register as a patient in our Health Centre, Huisartsenpraktijk Blaak. You are kindly requested to complete these forms and return them in person at the reception, accompanied
Welcome 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
Welcome 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
Tel: Fax:
Laith Farjo, M.D. Providing state of the art orthopedic care in a friendly environment Your Appointment: Time: Please complete the enclosed forms in ink and bring them with you along with your photo ID
Patient 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 #:
Practice Limited to Infants, Children, & Adolescents
Practice Limited to Infants, Children, & Adolescents 9290 SE Sunnybrook Blvd., #200, Clackamas, OR 97015 (503) 659-1694 5050 NE Hoyt St., #B55, Portland, Oregon 97213 (503) 233-5393 16144 SE Happy Valley
Patient 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
PATIENT 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
WITHOUT 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:
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
PATIENT 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:
Age: 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
Please be sure to confirm the location of your appointment
Beth DuPree MD, FACS, ABIHM Stacy Krisher MD, FACS, ABIHM Catherine Carruthers MD, FACS, ABIHM Amanda Woodworth, MD Please be sure to confirm the location of your appointment 45 2nd Street Pike 3300 Tillman
Patient 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.
Welcome to the Office of Dr. Sam Van Kirk!
Welcome to the Office of Dr. Sam Van Kirk! We understand that you have a choice in selecting your healthcare provider and we are pleased that you picked our practice. Our goal is to provide respectful,