We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal.
|
|
- Frank George
- 6 years ago
- Views:
Transcription
1 Appointment Date: Appointment Time: Dear Orion Member, We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal. Enclosed you will find our new patient paperwork. In order to minimize your wait, please take a few moments to complete the enclosed forms and bring it with you to your appointment. This is so we can better assist you with your healthcare needs. On the first day of your evaluation you will need to bring your enthusiasm and a positive attitude, we provide the rest. Again, thank you for your interest and we look forward to working with you! GOOD LUCK! Sincerely, Dr. Kroll and the Orion Staff
2 Welcome to our practice! Please Note: The first visit will take approximately 45 minutes to 1 hour. Please allow 24 hours notice for any cancellations. Being more than 15 minutes late to an appointment will result in rescheduling. New patients must bring a U.S. government approved I.D. For your convenience we accept cash, check, and credit cards. Payment for the evaluation is due at the time of service. Payments for all subsequent weigh-ins are due at the first visit of the week. All other visits for that week are included. We do not accept any insurance but some insurance companies do cover weight loss treatments. There is paperwork available that you may submit for repayment, but it is up to you to find out whether your insurance participates in this service. We require an EKG and blood work at the evaluation. Please do not wear any lotions or powders for the fact that it could interfere with these medical services. You are not required to complete the blood work outside of the office. Everything that is completed in the office that pertains to the assistance of your weight loss is included in the price of services.
3 Patient Information Name: Social Security #: Age: Date of Birth: Address: City: State: _ Zip: Home Phone: ( ) Cell Phone: ( ) Please Circle: Male Female Occupation: _ Emergency Contact Information: Emergency Contact Phone: ( )_ Please List Any Current Health Concerns/ Conditions/ Symptoms: Please List Any Surgeries You Have Had:
4 Medications Currently Taking: Please List Any Drug Allergies: Have You Been Seen By A Medical Doctor In The Last Six Months? Name Of Primary Care Physician: Female Patients Only Do You Have Regular Periods? Have You Had Any Pregnancies? Is There Any Way You Could Be Pregnant?
5 Weight History Current Weight: Goal Weight: _ Height: Do You Smoke? If Yes, How Much? Do You Drink? If Yes, How Much? What Do You Believe Is The Source Of Your Weight Gain? (ie. Family History, Eating Habits, Pregnancy) Do You Have Any Food Allergies, Dislikes, Or Cravings? Have You Attempted Any Other Diets? If So, How Many? Why Didn t They Work Out For You? What Is Your Level Of Activity? Please Circle One: (0 = Very Low and 5 = Very High)
6 What Dietary Problems Apply To You? Please Check All That Apply. Skipping Meals Carbohydrate Cravings Large Portion Size Too Much Alcohol Frequent Snacking Eating Fatty Foods Eating Out Frequently Stress Eating Eating Late Binging On Food What Is Your Motivation For Wanting To Lose The Weight? Please Check All That Apply. Unhappy With Appearance Need More Energy More Mobility Attending A Wedding/ Reunion Better Performance Gain Confidence Reduce Medications Upcoming Event/Vacation Clothes Do Not Fit Anymore Improve Health To Drop A Size To Improve Livelihood Other ( Please Describe)
7 Authorization of Medical Treatment I hereby authorize Dr. Brian C. Kroll, D.O. and his associates at First Choice Family Medical Center to provide any medical treatment, which in their judgment is deemed proper and medically necessary. Patient s Printed Name Patient s Date of Birth Patient, Guardian or Legal Representative s Signature Today s Date
8 Consent To Release Protected Health Information For Treatment, Payment, and Healthcare Operations I hereby authorize Dr. Brian C. Kroll, D.O. and his associates at First Choice Family Medical Center to release my personal protected information for treatment of my health condition to any other physician or healthcare provider directly or indirectly involved in my care and treatment. Direct involvement example: a specialist or hospital to which Dr. Brian C. Kroll has referred me to. Indirect involvement example: a laboratory, physicians of radiology or pathology. I understand that Mental Health, Substance Abuse, and HIV/AIDS related treatment will require an additional release of information authorization each time the information is requested for treatment purposes, except in any emergency treatment situation, as this is Dr. Brian C. Kroll s office policy. I understand that First Choice Family Medical Center will make all attempts to protect my confidential protected health information at all times. When the practice discloses my information it will be to authorized personnel and at the minimal amount of necessary information to accomplish the purpose. Some possible purposes include the purpose of billing, payment, and collections. I understand that I can request at any time an accounting of disclosure (release of information) for treatment, payment, or healthcare operations. I hereby consent and authorize First Choice Family Medical Center to use my protected health information for healthcare operations, such as quality assurance, improvement, healthcare oversight, and as required by federal and state laws. I understand that I may revoke this consent in writing at any time. Patient s Printed Name Patient s Date of Birth Patient, Guardian or Legal Representative s Signature Today s Date
9 Acknowledgment of Receipt of Notice of Privacy Practices I acknowledge that I have received a copy of First Choice Family Medical Center s Notice of Privacy Practices. I may request an additional copy from the practice at any time. I understand that I may ask if any changes have been made in the Notice of Privacy Practices, either each time I visit the office or by phone, and if there have been changes made to this Notice of Privacy Practices, the practice will provide me with a copy upon my request. Patient, Guardian or Legal Representative s Printed Name Relationship to Patient Patient s Printed Name Patient s Date of Birth To Staff Member: Upon request, a copy of this signed acknowledgment shall be supplied to the patient, guardian or legal representative. Staff Witness/Title Today s Date and Time Once processed, this form MUST be placed in the patient s medical records. Be sure to photocopy any ID s supplied by the patient, guardian, or legal representative. In the event of the patient s refusal to sign this acknowledgment, explain here and notify the provider. Initial, Date, and Time: Staff Witness/Title Today s Date and Time
10 Patient s Rights and Responsibilities Statement Statement of Patient s Rights Patients have the right to be treated with dignity and respect. Patients have the right to fair treatment, regardless of their race, religion, gender, ethnicity, age, disability, or source of payment. Patients have the right to have their treatment and other member information kept private. Only by law may records be released without patient permission. Patients have the right to easily access care in a timely fashion. Patients have the right to know all about their medical choices. This is regardless of cost or coverage by the patient s benefit plan. Patients have the right to share in the development of their plan of care. Patients have the right to information in a language they can understand. Patients have the right to have a clear explanation of their condition. Patients have the right to a clear explanation of their treatment options. Patients have the right to get information about their insurance carrier s services and role in the treatment process. Patients have the right to provide input on their insurance carrier s policies and services. Patients have the right to know the clinical guidelines used in providing and managing their care. Patients have the right to information about provider work history and training. Patients have the right to know about advocacy and community group and prevention services. Patients have a right to freely file a complaint, grievance, or appeal and to learn how to do so. Patients have the right to know about laws that relate to their rights and responsibilities. Patients have the right to know of their rights and responsibilities in the treatment process. Patient, Guardian or Legal Representative Signature Today s Date and Time
11 Patient s Rights and Responsibilities Statement Statement of Patient s Responsibilities Patients have the responsibility to treat those giving them care with dignity and respect. Patients have the responsibility to give providers information they need. This is so providers can deliver the best possible care. Patients have the responsibility to ask their providers questions about their care. This is so they can understand their role in that care. Patients have the responsibility to follow treatment plans for their care. The plan of care is to be agreed upon by the patient and provider. Patients have the responsibility to follow their agreed upon medication plan. Patients have the responsibility to tell their provider about medication changes, including medications given to them by others. Patients have the responsibility to keep their appointments. Patients should call their provider as soon as possible if they need to cancel visits. Patients have the responsibility to let their provider know when the treatment plan no longer works for them. Patients have the responsibility to let their provider know about problems with paying fees. Patients have the responsibility to not take actions that could harm others. Patients have the responsibility to report abuse. Patients have the responsibility to report fraud. Patients have the responsibility to openly report concerns about quality of care. Patient, Guardian or Legal Representative Signature _ Today s Date and Time
12 Weight Loss Bill of Rights WARNING: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 ½ pounds to 2 pounds per week or weight loss of more than 1% of body weight per week after the second week of participation in a weight loss program. Consult your personal physician before starting any weight loss program. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long term weight loss. Qualifications of this provider are available upon request. You Have a Right To Ask questions about the potential health risks of this program and its nutritional content, physiological support, and educational components. Receive an itemized statement of the actual or estimated price of the weight loss program, including extra products, services, supplements, examinations, and laboratory tests. Know the actual or estimated duration of the program. Know the name, address, and qualifications of the dietitian or nutritionist who has reviewed and approved weight loss program according to s (1)(j), Florida Statutes. Patient, Guardian or Legal Representative s Signature Today s Date
13 Controlled Substance Agreement Controlled substance medications are very useful but have a high potential for misuse and are, therefore, closely controlled by local, state and federal governments. Because my physician is prescribing controlled substance medications, I agree to the following conditions: 1. I am responsible for the controlled substance medication supplied to me. Refills will not be made if they RUN OUT EARLY, LOSE A PRESCRIPTION, or if MEDICATION HAS BEEN STOLEN. I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. I understand that I MUST be seen in the office every week in order to continue receiving prescription refills. Initials 2. I understand that the main treatment goal is to promote weight loss and improve my health. In consideration of this goal, and the fact that I am being given a potent medication to help me reach this goal, I agree to help myself by following better health habits such as exercising, weight control and the avoidance of the use of tobacco and alcohol. I must also comply with the treatment plan as prescribed by my physician. Initials 3. Female patient: I am aware that it is my responsibility to immediately inform the treating physician if I plan to or become pregnant. Pain management treatment including medications and injection therapy could result in harmful effects to the developing fetus. Initials 4. I understand that ID and signature are required for me or another individual to pick up prescriptions. Initials 5. I understand that if I violate any of the above conditions, my prescription for controlled substance medications may be terminated immediately. If the violation involves obtaining controlled substance medications from another individual, or the use of non-prescribed illicit (illegal) drugs, I may also be reported to all of my physicians, medical facilities, and appropriate authorities. Any repeated violation listed above could lead to being discharged from the Orion Rapid Weight Loss Program. Initials
14 Acknowledgment of Agreement I,, declare that I have received, read, understand, and agree with the Controlled Substance Agreement. The same will be explained to me by the physician as well. In addition, I fully understand the consequences of violating this agreement. Patient, Guardian or Legal Representative s Signature Today s Date Staff Witness/Title Today s Date and Time *This form is a necessary response due to changing regulations and enforcements. There is no assumption that you will purposely misuse your medications.
15 Waiver of Liability I have elected to seek medical treatment at the Orion Rapid Weight Loss Program, at the office of Dr. Brian C. Kroll, D.O. and understand that I am personally responsible for the payment of all services rendered. Any money owed will be paid in full on or before your next visit. Patient, Guardian or Legal Representative s Signature Today s Date
16 How Did You Hear About Us? Please let us know how you heard about our weight loss program, whether it was through one of our sources of advertisement or by word of mouth. Orion Rapid Weight Loss Program provides a rewards plan for those that refer patients to our office. For every patient that is referred to us and begins the program, we provide one free week. Please Circle: Commercial Billboard Newspaper/Newsletter Internet Friend Name:
17 Authorization to Utilize/Release Weight Loss Photographs I,, authorize Orion Rapid Weight Loss and Dr. Brian Kroll to use photographs I have provided for promotional, advertising, and marketing purposes as they see fit and appropriate. These marketing uses may include, but are not limited to: in-office bulletin board(s), website, flyers, television, commercials, etc. I release all copyrights to Orion Rapid Weight Loss for the aforementioned purposes. I understand that my photographs will not be sold or used for means other than marketing and advertising for Orion Rapid Weight loss exclusively. Patient, Guardian or Legal Representative s Signature Today s Date
INFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of client) agree and consent to participate in behavioral healthcare services offered and provided by Methodist Services - Community Counseling Services (CCS). I
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 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 informationBasic Information. Date: Patient s Name: Address:
1 Basic Information : Patient s Name: Address: Home Phone: Work Phone: Cell Phone: Email: Age: Birth : Marital Status: Occupation: Educational History: Name, Address and Phone of Child s School Counselor
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 informationSignature (Patient or Legal Guardian): Date:
X-Ray Patient Information: [ ] Male [ ] Female Patient Name: Date of Birth: / / SS#: Mailing Address: City: State: Zip: Phone # s: (Home) (Work) (Cell) Referring Physician: Phone #: /Fax#: Additional Physician:
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 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 informationINFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care
More informationTHE PAIN TREATMENT CENTER, INC. d/b/a STONE ROAD SURGERY CENTER
THE PAIN TREATMENT CENTER, INC. d/b/a STONE ROAD SURGERY CENTER PATIENT INFORMATION GUIDE 280 Pasadena Drive Lexington, Kentucky 40503 (859) 278-1316 Visit us on the Web at www.pain-ptc.com Dear Patients
More informationSt. Mary s Industrial Medicine 4017 Atlanta Hwy, Ste B Bogart, GA Phone: (706) Fax: (706)
Please Fill Out Completely: St. Mary s Industrial Medicine Patient s Last Name First Name MI Social Security Number Date of Birth Age Gender Race Marital Status Ethnicity (Circle one): Language Latino
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 informationBeck & Blackley Chiropractic Clinic
Address City State Zip Code Home Phone Cell Phone Work Phone Email Address Sex: M F Marital Status: M S D W Date of Birth SS# Spouse Name How did you hear about our office? Employer Name/Occupation Emergency
More informationTHE COUNSELING PLACE ADULT INTAKE FORM Yearly Family Income:
Person to Contact in Case of Emergency Name Relationship Best Contact Number Alternative Contact Number Office Use Only Intake Date Reason for referral Counselor THE COUNSELING PLACE ADULT INTAKE FORM
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 informationOutpatient Wellness Clinic
Outpatient Wellness Clinic Patient Name: Date of Birth: Address: Phone: Email: Emergency Contact: Relationship: Phone: What is the reason for the appointment? Who were you referred by? (Physician, agency/
More informationCadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE
Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE Date: / / Name: Date of Birth: / / Age: Sex: M F ETHNIC ORIGIN: White Hispanic Haitian African American Other: PRIMARY LANGUAGE: English Spanish
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 informationX Name of Patient (Please Print) X Signature of Patient (or Parent/Legal Guardian) X Name of Parent/Legal Guardian (Please Print)
In Office Policies Identification - For the protection of our patients, and to reduce medical identity theft, all patients are required to present a valid insurance ID card and/or driver s license at the
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 informationAddress City, State Zip Code Phone
Email Correspondence Authorization Patient Name Date of Birth Address City, State Zip Code Phone By signing this form, I authorize Angela Pifer, Certified Nutritionist and 28 Day Health Solutions Co. (Angela
More informationPain Management Specialists of Southfield Michigan. Michigan Orthopaedic Institute. Thank you for choosing us for your Pain Management Services.
Cain E. Dimon, M.D. Craig S. McCardell, M.D. Helen Puffenberger, PA C Pain Management Specialists of Southfield Michigan A Division of: South Oakland Anesthesia Associates Providing Services at Michigan
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 Please Print
PATIENT INFORMATION Please Print DATE Patient s Last Name First Name Middle Name Suffix Gender: q Male q Female Social Security Number of Birth Race Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred
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 information*3ADV* Patient Rights & Responsibilities Advanced Directive Page 1 of 2. Patient Rights & Responsibilities. Patient Label
PATIENT RIGHTS Portneuf Medical Center encourages respect for the personal preferences and values of each individual and supports the Rights of each patient and resident of the Center, or their representative
More informationLalita Matta, MD Estrela Chaves, NP, CDE
PERSONAL INFORMATION Name of Patient: Maiden Name: Social Security No.: Date of Birth: Home Address: City: State: Zip: Home Phone: Mobile Phone: Work Phone: Email Address: Race/ Ethnicity: Marital Status:
More informationWELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice.
WELCOME Those of us at Crossroads Counseling want to thank you for choosing to work with us and we want to make your time with us as productive as possible. In order to expedite the intake process, please
More informationCamp JRA will be held at Camp Victory in Millville, PA, from July 19-24, Counselors are required to attend staff orientation on July 18 th.
Dear Prospective Counselor, Thank you for your interest in being a Camp JRA (Juveniles Reaching Achievement) counselor. We are excited to be planning for a fun-filled week for our campers in 2015. Camp
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 informationPerson to Contact in Case of Emergency. THE COUNSELING PLACE YOUTH INTAKE FORM Yearly Family Income:
Person to Contact in Case of Emergency Name Relationship Best Contact Number Alt. Number Office Use Only Intake Date Reason for referral Counselor Who Can Pick Up Client (if Minor) THE COUNSELING PLACE
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 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 informationAPPOINTMENT INFORMATION SHEET
APPOINTMENT INFORMATION SHEET All appointments for new patients will require a one-time, refundable deposit of $50.00 to secure your appointment. You may use cash, check or credit card. The check or credit
More informationPATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments.
PATIENT NOTICE Our goal at is to provide quality medical care. Because of our concern for your health and well-being, there are certain types of medications we may not be able to prescribe to you. Examples
More informationHouston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you
More informationStudent Participant Health Form
Participant Name: Male Female Birth Age on arrival at program Month/Day/Year To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. 1. 2. Complete pages
More informationADMISSION FORM. Employment Status: Retired Unemployed Employed Full Time Employed Part Time
Patient ID Number A. PATIENT INFORMATION: First Name & Middle Initial: Home Address: ADMISSION FORM Last Name: Apartment Number: City: State: Zip: Phone: Home Cell Second Phone: Work Cell Email Address:
More informationRotary District 5180/5190 RYLA REGISTRATION FORM 2018
Rotary District 5180/5190 RYLA REGISTRATION FORM 2018 ROTARY CLUB OF: ROTARY CLUB CONTACT: This form must be completed in full and signed by the student as well as a parent or legal guardian in multiple
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 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 informationComprehensive Counseling & Consulting, LLC
Welcome to Comprehensive Counseling & Consulting, LLC! We look forward to working with you! Below you will find the intake packet which may be printed out and completed before your first appointment. We
More informationLives (circle one): in assisted living with a relative alone
Patient name: How did you hear about us? Lives (circle one): in assisted living with a relative alone Current address (include name of assisted living or independent living facility if applicable): Current
More informationPATIENT INFORMATION. In Case of Emergency Notification
PATIENT INFORMATION Patient Name Date Nickname DOB Age Sex Race/Ethnicity Language(s) spoken at home Person completing form Relation to Patient Patient Address City State Zip Phone # Other Phone Medical
More informationSPRING BRANCH COMMUNITY HEALTH CENTER
Hillendahl Clinic 1615 Hillendahl Blvd., Suite 100 Houston, TX 77055 (713) 462-6565 Pitner Clinic 8575 Pitner Road Houston, TX 77080 (713) 462-6545 Mon, Wed, Fri: 8am-5pm Tues & Thurs: 8am-8pm 1 st & 3
More informationNPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:
More informationcomplete the required information. Internet access is provided in our office, if needed.
K State Research and Extension Dickinson County 712 S Buckeye Avenue Abilene, KS 67410 (785) 263 2001 dk@listserv.ksu.edu Dear Potential Dickinson County 4 H Volunteer, Thank you for your interest in volunteering
More informationDo You Qualify? Please Read Carefully:
Do You Qualify? Please Read Carefully: You are NOT eligible if any of these apply: I am pregnant I am under the age of 18 I have more than two children in my custody My child(ren) is(are) three years old
More informationVOLUNTEER APPLICATION
VOLUNTEER APPLICATION Name: Age: Date of Birth: Social Security : Address: City: State: Zip Phone: Work: Cell: Email Address: How can we reach you? Home phone Cell phone Text Email Work phone Employer/School:
More information1.2 ADULT CLIENT INTAKE FORM: Client Information
1.2 ADULT CLIENT INTAKE FORM: Client Information FOR OFFICIAL USE ONLY: Client Number Effective Insurance No OH No CLIENT INFORMATION Client name of significant other CHILDREN INFORMATION of birth of birth
More informationPatient Registration Form
Padma Sripada MD, Columbia Internal Medicine 2500 Pond View, Suite 202 Castleton on Hudson, NY 12033 Phone: 518-391-2889 Date: Patient Registration Form First Name Middle Last Name... Sex: M F Preferred
More informationNew Patient Information
New Patient Information PATIENT INFORMATION M / F Last Name First Name Middle Name Suffix- Jr, Sr, etc. Mr, Mrs, Ms, Dr Sex Date of Birth Social Security Number Alias- Nickname (Last, First, Middle) Permanent
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 informationWelcome 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,
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 informationPATIENT INSTRUCTIONS FOR PAPERWORK
330 Mallory Sta-on Rd., Suite B3 Franklin, TN 37067 Ph. 615-944-3530 Fax. 615-550.2641 PATIENT INSTRUCTIONS FOR PAPERWORK Thank you so much for trus0ng your care to Integra0ve Family Medicine. A
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 information12 King Philip Rd. Sudbury, MA (585)
Dear Parents, In order to get started with speech therapy services including screening, evaluation, and treatment, we ask that you submit the following registration paperwork to Sudbury Speech and Language
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 informationClient Information Form
Client Information Form Please read and complete all information requested. Date: Name: Address: City, State and Zip: Social Security Number: Home Phone: Work Phone: Cell Phone: E-mail: If client is a
More informationCounseling Center of Montgomery County
Counseling Center of Montgomery County 212 Conroe Drive (936) 760-1880 Office Conroe, TX 77301 (936) 760-2915 Office CCMC@CounselingCenterMoCo.com (936) 760-9101 Fax CHILD/ADOLESCENT PSYCHOSOCIAL HISTORY
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 informationHEALTH HISTORY QUESTIONNAIRE
Patient Name: of Birth: HEALTH HISTORY QUESTIONNAIRE Primary Care Physician: Other physicians you currently see: Emergency Phone #: Contact Person/Relationship: Reason for the Visit: Please list your medications
More informationSPOUSE/GUARDIAN (If patient is married, give spouse information. If patient is a child, give parent information.)
Please Fill Out Completely: St. Mary s Women s Center 1000 Cowles Clinic Way, Suite D-300 Greensboro, GA 30642 762-243-3860 phone 762-243-3879 fax Patient s Last Name First Name MI Social Security Number
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 informationEpic Pain Management & Anesthesia Consultants, LLC PO Box 1779, Fort Lee, NJ REGISTRATION FORM
REGISTRATION FORM Name (First) (Middle) (Last) M F Social Security of Birth Age Marital Status Single Married Civil Union Widow/ Widower Home Address City State Zip Code Work Address (Cell) (Home) (Work)
More informationPlease Print Affiliation (school, company name, etc): Mailing Address: City: Postal Code: Home Phone: Cell Phone: Work: Date of Birth (DD/MM/YY):
Name: Volunteer Application Thank you for your interest in volunteering with Habitat for Humanity Wellington Dufferin Guelph. The information you provide will help us to place you in a volunteer position
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 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 informationThank you, in advance, for being a partner in your care.
477 Cooper Road, Suite 220 Westerville, OH 43081 614-818-0215 Your appointment with: Dr. David H. Brown Dr. Jed W. Henry Dr. Adam J. Clemens is scheduled for. Welcome to our practice. It is our desire
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 informationWelcome to the office of JillAnne W. McCarty, MD, PhD. We are looking forward to meeting you.
Welcome to the office of JillAnne W. McCarty, MD, PhD. We are looking forward to meeting you. For your convenience, attached are forms for you to fill out and bring to your visit. Information on our general
More informationInitials of State and Out of State DL # Complete as Applicable
Bridgeway Center Inc. Community & Court Education Services Enrollment Form Have you ever attended any classes at Bridgeway Center, Inc.? Yes No Today s Date First Name Middle Name Last Name / / Address
More informationWELCOME TO OUR OFFICE!
WELCOME TO OUR OFFICE! Name Date: / / Address City State Zip Home Phone Cell Phone E-Mail Birthdate Age SS# Race: Marital Status: M W D S Employer Work Phone Occupation Name & Birthdate of Primary Insured
More informationHuntington University Nursing Career Academy Application Process Summer 2015
Application Process Eligibility Requirements: applicants must be in 10 th, 11 th, or 12 th grade during the 2014-2015 academic school year and be interested in exploring a career in nursing. Program cost:
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 informationNutritional Health Questionnaire
Name: Today s date: Address: City: State: Zip: Email address: Skype contact (if applicable): Home Phone: Work phone: Cell Phone: What numbers are best for detailed messages? What is your preferred method
More informationHouston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you
More informationGuide to Accessing Quality Health Care Spring 2017
Guide to Accessing Quality Health Care Spring 2017 MolinaHealthcare.com 5771749DM0217 MyMolina MyMolina is a secure web portal that lets you manage your own health from your computer. MyMolina.com is easy
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 informationJames B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL
James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL 34471 352-867-0444 Dear Patients: Welcome to our orthopaedic office. We appreciate your confidence and will take great
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 informationDear New Patient, Once again, we would like to thank you for choosing us as your primary health care provider. We look forward to working with you.
307 West Central Street Wendy J. Parker, M.D. Natick, MA 01760 Deborah J. Riester, M.D. Telephone: 508-820-8383 Jo-Ann Suna,M.D. Fax: 508-820-0250 Hadia F. Tirmizi, M.D. Natalia Sedo, N.P. Christine Chang,
More informationW e l c o m e t o B i l l e r i c a C h i r o p r a c t i c
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c N E W P A T I E N T I N T A K E F O R M Print Name Today s Date Address City State Zip Email Address Date of Birth Male Female Social Security
More informationWelcome to the beginning of optimal health!
Welcome to the beginning of optimal health! would like to thank you for choosing us to partner with you as you embark on your journey towards optimal health! We ve developed this guide to help you prepare
More informationCERTIFIED CLINICAL SUPERVISOR CREDENTIAL
REQUIREMENTS: CERTIFIED CLINICAL SUPERVISOR CREDENTIAL Applicants must live or work at least 51% of the time within the jurisdiction of ADACBGA, or live or work in a jurisdiction that does not offer the
More informationCATARACT AND LASER CENTER, LLC
CATARACT AND LASER CENTER, LLC Patient Information Date: Patient Name: M F Address: Street City State Zip Home Phone: Work Phone: Cell Phone: E-Mail : Referred by: Medical Doctor: Who is your regular eye
More informationAffordable Concierge New Patient Registration
Affordable Concierge New Patient Registration Patient Information Last name: First name: MI: DOB: [ ] Male [ ] Female Home address: City: State: Zip: Billing address: [ ] Same as home City: State: Zip:
More informationDr. Albert F. Bravo Gastroenterology / Internal Medicine
Dr. Albert F. Bravo Gastroenterology / Internal Medicine Name: First Middle Last Spouse s name: Email: Please check one: Married Single Widowed Divorced Ethnicity: Race: Language Preferred: Home Address:
More informationChildren s Residential Treatment Center Medical Intake Information
Children s Residential Treatment Center Medical Intake Information The following is required at/by intake: q Copy of Current Insurance Cards (Medical, Dental, or Medical Assistance) q Proof of Physical
More informationPREOPERATIVE PATIENT QUESTIONAIRE
PREOPERATIVE PATIENT QUESTIONAIRE Name Age Sex Ht Wt PATIENT INFORMATION New Patient Name Change Address Change Insurance Change This questionnaire is designed to assist the anesthesiologist who will be
More informationPETER BOWER, M.D Rolkin Court, Suite 301. Charlottesville VA (434) F(434) Today's date. Name:
PETER BOWER, M.D. A N D A S S O C I A T E S 1415 Rolkin Court, Suite 301 Charlottesville VA 22911 (434)964-0159 F(434)978-1667 Today's date Name: Date of Birth: Male Female Social Security # Mailing Address:
More informationRe-Vita -Life. Sub-dermal Bio-identical Pellets
Re-Vita -Life Sub-dermal Bio-identical Pellets Welcome and thank you for inquiring about Re-Vita-Life Bio-identical hormone replacement therapy. We have included a new patient information packet which
More informationWelcome to the beginning of optimal health!
Welcome to the beginning of optimal health! would like to thank you for choosing us to partner with you as you embark on your journey towards optimal health! We ve developed this guide to help you prepare
More informationIvis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801
How did you hear of our office? New Patient Registration SECTION 1: PATIENT INFORMATION Patient Name: M / F Date of Birth: Address: City: State: Zip Code: SECTION 2: PARENT / GUARDIAN / INSURANCE Name:
More informationMR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?
MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET First: MI: Last: of Birth: Age: Gender: Male Female Mailing Address: Physical Address: May we send you text messages relating
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 informationCooley Chiropractic. Date of Birth. Married Single Spouse Name. Street City State Zip. . Name. Occupation. Current Symptoms. When Symptoms began
Please Print Clearly Date NAME: Date of Birth Male Female Married Single Spouse Name Address: Street City State Zip Home Phone Cell Phone E-mail In Case of Emergency please contact: Name Phone Relationship
More informationFax: Do not mail the forms!
Associates in Pediatric and Adult Urology The Morristown Medical Center Health Pavilion 333 Mount Hope Avenue Suite 250 Rockaway, NJ 07866 973-895-6636 Dear New Patient: Welcome to Associates in Pediatric
More 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 information