Last Name First Name M.I. DOB. Employer Name Employer Phone ( ) Address City State Zip Code

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1 Patient Registration Form Arizona Community Physicians 6130 N. La Cholla Blvd, Suite 100, Tucson, Arizona Phone Last Name First Name M.I. DOB Home Phone ( ) Cell Phone ( ) ER Phone ( ) Emergency Contact Phone ( ) Marital Status Married Single Divorced Separated Widowed Sex M F Address Race (optional) Ethnicity (optional) Language (optional) Primary Care Physician Student: FT PT Previous Name Employer Name Employer Phone ( ) Employer Address Guarantor Information (If different than the Patient) Last Name First Name M.I. Address City State Zip Code Home Phone ( ) Primary Insurance Information (Please present Insurance Card at Reception Desk) Insurance Eff Date Name Insurance Carrier Group ID # Policy ID # Insurance Address City State Zip Code Relationship of Patient to Subscriber Self Spouse Child Other (Explain) Subscriber DOB Subscriber SS# Sex M F Subscriber Employer Name Employment Phone ( ) Employer Address City State Zip Code Secondary Insurance Information Insurance Eff Date Name Insurance Carrier Group ID # Policy ID # Insurance Address City State Zip Code Relationship of Patient to Subscriber Self Spouse Child Other (Explain) Subscriber DOB Subscriber SS# Sex M F Subscriber Employer Name Employment Phone ( ) Employer Address City State Zip Code By signing this form, I hereby authorize and request payment of medical benefits for services and/or supplies rendered to me be paid directly to ARIZONA COMMUNITY PHYSICIANS, P.C. or its authorized representative. I authorize release of any medical record or other information necessary to process claims, related to such services, to government benefit programs or other medical insurance payers. I further permit a copy of this authorization to be used in place of the original. By signing, I understand that regardless of any available insurance plan or program, I am financially responsible for any incurred charges. The effective period of this authorization is from today s date to a future date, when I am no longer a patient of the Arizona Community Physicians, P.C. group or am deceased. PATIENT OR GUARDIAN SIGNATURE DATE LACH-127 REV. 7/13

2 MRN# No Show Policy Arizona Community Physicans, P.C. Our goal is to provide quality medical care on a timely manner. In order to do so we have to implement an appointment cancellation policy. The policy enables us to better utilize available appointments for our patients in need of medical care. A patient who does NOT SHOW for their appointments and who does not notify the office 24 hours in advance, may be charged an administrative fee of $25. This fee is not payable by any insurance company, and remains the responsibility of the patient. This is due in full prior to your next appointment. We ask that you please call 24 hours in advance to if you are unable to keep your appointment. Prescriptions Prescription refills: Call your pharmacy for refills on medications. Please allow 48 hours for a prescription to be refilled. If you have not had an appointment within a year you may need to have an appointment before we refill your medication. Narcotic prescriptions (pain pills, sleeping pills, nerve pills and muscle relaxers): We will not fill on Fridays. If you need a prescription that requires a physician to write the prescription and an original signature, that will be handled Monday thru Thursday. You will be required to come to the office to pick up the prescription. Forms Completion Fees There are fees charged for completing forms. They are not covered by insurance and are the responsibility of the patient. There are many different types of forms and are as diverse as the institution requesting the form. It may not be possible to determine what fee will apply to the form until the physician reviews it. The cost could range from $ in most cases. We will call you to get approval for any form completion with a charge more than $50. I have read and acknowledge the above information. Signature Date LACH-131 REV. 4/13

3 Arizona Community Physicians Drs. Carter, Rothe, Lowry, Hee, & Haase Adult Health Questionnaire Page 1 Patient name: MRN DOB: Date: Constitutional A: Recent weight change? B: Fevers, Chills, or Night sweats? C: Fatigue? YES NO Comments Eyes A: Difficulty seeing? B: Contact lenses or glasses? C: Temporary loss of vision? Ears, Nose, and Throat A: Problems with hearing? B: Hoarseness, sore throat, or trouble swallowing? C: Nose Bleeds? Cardiovascular A: History of murmurs? B: Chest pain? C: Known heart rhythm problems? Respiratory A: Cough? B: Shortness of Breath? C: Wheezing or asthma symptoms? D: Coughing up blood? Gastrointestinal A: Constipation or Diarrhea? B: Abdominal pain? C: Recent change in appetite? D: Blood in stool? E: Heart burn? F: Nausea or vomiting? Genitourinary A: Frequent urination? Trouble urinating? B: Incontinence? C: Blood in urine? D: Painful urination? For Females Last menstrual period? Birth control method? A: Vaginal discharge? B: Irregular or painful menses? C: Bleeding after menopause? LACH-138-1

4 Arizona Community Physicians Drs. Carter, Rothe, Lowry, Hee, & Haase Adult Health Questionnaire Page 2 Patient name: DOB: Genitourinary continued For Males A: Difficulty obtaining an erection? B: Difficulty with urine stream? YES NO Comments Musculoskeletal A: Joint pain or swelling? B: Calf or leg pain with walking? C: cold extremities? Skin A: Rashes? B: Skin cancers? C: Other skin issues? Neurologic A: Minor stroke? B: Recent numbness or tingling? C: History of seizures? D: Extremity weakness? Psychiatric Endocrine Hematology/Lymphatics Breast A: Depression? B: Anxiety? C: Other psychiatric disorders? A: History of high or low blood sugar? B: Heat or cold intolerance? C: Thyroid problems? A: Easy bruising? B: Swelling in legs? C: Anemia? D: Enlarged nodes or glands? A: Pain? B: Nipple discharge? C: Other changes or abnormalities? LACH-138-2

5 PERSONAL MEDICAL HISTORY MRN: (admin use only ) Date Name Birthdate Age Which medical provider are you seeing today? Dr. Carter Dr. Rothe Dr. Lowry Sue Medlen, FNP Dr. Hee Dr. Haase Amy Brunsvold, FNP Neal Bohnsack, FNP Who referred you to our office? What is the main reason for your visit today? Please list your medications, include dosage and number per day: Medication Dose Frequency (x per day) Are you currently taking any of the following nonprescription medications? Aspirin? Ibuprofen? Tylenol? Allergy Medication? Laxatives? Vitamins or Supplements? Please list any medications you are allergic to and the reaction: Medication Reaction Are you on a special or modified diet? Preferred Pharmacy and Location? Mail Order Pharmacy? LACH /14

6 What is/was your occupation? Spouse? Marital status? M-S-W-D Do you use tobacco? Do you drink alcohol? Education? High School/GED College Other Yes If so, how much? No Ex-smoker, quit in year Yes No Do you exercise? Yes No What? List Illness or operations requiring hospitalization and year of problem: Please indicate the year you may have had the following tests or vaccinations: Physical exam Pap Smear Mammogram Bone density/dexa Colonoscopy PSA/prostate EKG Cholesterol Audiogram/hearing test Vaccines: Tetanus Shingles Pneumonia Other vaccines Who in family had? Diabetes High Blood Pressure Cancer (type) Heart Attack before age of 60 Stroke before age of 60 Asthma Colon Polyps Other (specify) FAMILY HISTORY Father Mother Grandparent Brothers Sisters Please list other physicians you have seen in the last two years and reason: LACH /14

7 Northwest Tucson 10 Thornydale Rd. Tangerine Road Ina Road River Road First Ave. Oracle Road 6130 N. La Cholla Suite 100 La Canada Blvd. Northwest ACP Imaging Center 2191 W. Orange Grove Rd. La Cholla Blvd. River Road Orange Grove Road River Road N Drs. Carter, Rothe, Lowry, Hee & Haase Family Practice Dorota Pucyk M.D., Endocrinologist Nurse Practitioners: Sue Medlen, Neal Bohnsack & Amy Brunsvold on the campus of Northwest Medical Center 6130 N. La Cholla Blvd., Suite 100, Tucson, AZ Phone: (520) Fax: (520)

8 Drs. Carter, Rothe, Lowry, Hee & Haase Family Practice To W. Ina Rd. Urological Associates Carondelet Surgery Center Walgreens Valero Corner Store To N. Oracle Rd N. La Cholla Blvd. Desert Life Medical Buildings W. Orange Grove Rd PACU/Surgery MEDICAL ST. Desert Life Rehabilitation and Care Center 1919 W. Medical St. Northwest Medical Center ER/ Outpatient 6200 N. La Cholla Blvd. Western Arizona Radiology Northwest Medical Plaza Life Care Center W. HOSPITAL DRIVE Northwest Professional Bldg W. Hospital Dr. J2 Lab Parking Garage HealthSouth Rehabillitation Hospital 1921 W. Hospital Dr. La Cholla Medical Plaza Enlarged Building View Suite 100 Carter, Rothe, Lowry, Hee & Haase AZ Oncology/Urology 2070 W. Rudasill Rd. W. RUDASILL RD. Radiology Ltd. Parking N. FOUNTAIN PLAZA DR. Desert Cardiology 6130 N. La Cholla Blvd. Entrance Entrance 6130 N. La Cholla Blvd. To W. River Rd. Northwest Medical Park 1845 W. Orange Grove Rd. Arizona Oncology N. CORONA RD. Rillito Nursery Orange Grove Medical Office Bldg W. Orange Grove Rd. Northwest Tucson Surgery Center N. LA CHOLLA BLVD. Medical Suites Quik Mart Medical Suites ACP Northwest Imaging 2191 W. Orange Grove Rd. Palm Canyon Apartments W. ORANGE GROVE RD. The Women s Center 1920 W. Rudasill Rd. Sonora Behavioral Health Hospital 6050 N. Corona Rd. The Fountains at La Cholla 2001 W. Rudasill Rd. Dorota Pucyk M.D., Endocrinologist Nurse Practitioners: Sue Medlen, Neal Bohnsack & Amy Brunsvold on the campus of Northwest Medical Center 6130 N. La Cholla Blvd., Suite 100, Tucson, AZ Phone: (520) Fax: (520) LACH-104 Rev. 2/15 N

9 John Z. Carter, MD Harold D. Lowry, MD Loan P. Haase, MD Amy N. Brunsvold, FNP Thomas C. Rothe, MD Darren P. Hee, MD Sue Medlen, RN, FNP Neal P. Bohnsack, FNP Affiliated with Arizona Community Physicians 6130 N. LaCholla Blvd. Suite 100 Tucson, AZ Telephone: (520) Fax: (520) Patient: Address: Date: Appointment Date and Time: We are pleased to welcome you as a new patient in our office. Please arrive about 20 minutes early to familiarize yourself with our location and to allow us time to add/update you in our computer system. Please complete the enclosed Initial Medical History Form prior to your visit. These appointments are often scheduled months ahead of time. If you need to cancel or reschedule, please let us know IMMEDIATELY. The purpose of this visit is to get acquainted and is scheduled to last about minutes. It is NOT a complete physical exam but intended to address your primary medical concerns. We will be happy to renew prescriptions (please bring in your bottles) and deal with your health issues in the time allotted. We may indeed want you to schedule a follow up visit or a complete physical exam but will determine this after assessing your needs. The following is a checklist of things to do or bring for your visit: Yourself, 20 minutes early for computer updating and insurance verification Completed Initial Medical History Form Current insurance cards/information (VERY IMPORTANT) Bottles/list of medications to be filled or renewed We likely will need medical records from your previous physician. We ask that you bring the name and address of the physician(s) who have the most significant medical records. We will have you fill out a Release of Records Form(s) in the office to obtain the records. These can take up to a month or more to arrive at our office. We look forward to meeting you soon and assisting in your medical care. Receptionist for LACH-112 7/14