th Ave NE * Olympia, WA *

Similar documents
Pediatric Patient History

Pediatric New Patient Form

Kent State University Health Services. Medical History Form

INSURANCE INFORMATION

PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX

Medical History Form

Sage Medical Center New Patient Forms

Welcome to University Family Healthcare, PA.

PATIENT S NAME: LAST NAME: FIRST NAME: MI: DOB: MARRIED: SINGLE: SOCIAL SECURITY: HOME ADDRESS: APT# CITY: STATE: ZIP: CELLULAR PHONE:

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

Broomall Patients ONLY may send forms via to:

Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801

PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE (MR: )

From: AR Center (Arkansas Center for the Study of Integrative Medicine)! PLEASE READ FIRST!!

Patient Information Form

PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip

Choptank Community Health System Caroline County School Based Health Centers Healthy Children Are Better Learners MEDICAL

Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)

HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.

PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!

Developmental Pediatrics of Central Jersey

Patient s Legal Name: Preferred Name: First Middle Last

Welcome Letter- Orchard School Clinic

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

The process has been designed to be user friendly and involves a few simple steps.

12086 Ft. Caroline Road, Suite #401, Jacksonville, FL Phone: (904) Fax: (904) Patient Full Legal Name Date

WELCOME TO OUR OFFICE!

Amarillo Endoscopy Center Srinivas Pathapati, MD., PA 6833 Plum Creek Drive Amarillo, TX (806)

School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE Phone: Fax:

Case History: Family Information: Today s date (mm/dd/yyyy): Child s Name: Date of Birth: / / Age: Gender: Male / Female

X Name of Patient (Please Print) X Signature of Patient (or Parent/Legal Guardian) X Name of Parent/Legal Guardian (Please Print)

Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self

New Patient Registration Form NJR_NP_F100

SHORELINE ALLERGY & ASTHMA ASSOCIATES, LLP

The Home Doctor. Registration Checklist

Patient Registration Form Pediatrics

BACK FOR ANOTHER Come and YEAR celebrate

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:

DECLARATION AND CONSENT TO TREATMENT

PATIENT INFORMATION Indiana Plastic Surgery Center, PC

Print Guardian Name (If not patient) DOB: Patients Name: (Last, First, MI): Circle One: - - / / Mailing Address: Apt. #: City: State: Zip Code:

CORAZON PANES SANCHEZ., M.D., L.L.C.

NORTH COUNTY PHYSICAL THERAPY, INC. DBA MISSION PHYSICAL THERAPY GROUP

NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

Practice Limited to Infants, Children, & Adolescents

2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name

PATIENT INSTRUCTIONS FOR PAPERWORK

Medications List. Allergies. Drug Name Dosage Directions Reason Taking

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:

Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)

New Patient Paperwork

NEW PATIENT INFORMATION

ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION

Please be sure to bring your insurance card(s) and required co-payment (if any) to the appointment.

Page 1 of 5 1/4/17. Print Guardian Name (If not patient) DOB: Circle One: - - Patients Name: (Last, First, MI):

Reminders for you as you come in for your first appointment

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address

Dodge. County. Schools

PATIENT REGISTRATION FORM (ecw)

PATIENT INFORMATION. Last Name: First Name: MI: Date of Birth: SS #: Gender: Male Female. City: State: Zip Code:

ALFRED ALINGU, MD INTERNAL MEDICINE

Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:

Welcome to Hawaii Women s Healthcare

Fulcrum Orthopaedics Patient Registration Packet

Thank you for choosing Oakland Medical Center as your Patient-Centered Medical Home

2017 Medi-Slim Weight Loss Patient Information Form

(Please Print) PATIENT INFORMATION. Sex: Male Female Home phone no: ( ) City: State: Zip: Cell phone no: ( ) Occupation: Employer: Work phone no: ( )

Dear 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.

PATIENT REGISTRATION

School Based Health Consent for Services Grace Community Health Center, Inc.

Columbia Medical Practice- Pediatrics Ken Klebanow M.D. and Associates

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax:

Lavaca SBHC Providers, Services, Hours, and How to Make an Appointment

Affordable Concierge New Patient Registration

PATIENT REGISTRATION FORM

Look for us in your neighborhood and know that we are committed to working with you to make the best health care decisions for your family.

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION

Name DOB / / SS# / / Street Address City/State/Zip. Home ( ) - Cell( ) - Work( ) - Emergency Contact Day Phone( ) -

Fulcrum Orthopaedics Patient Registration Packet

PATIENT INFORMATION FORM

Patient Information & Medical History Nurse/Doctor appointment

Welcome to St. Bonaventure University. We are glad you re here!

Northeast Kingdom Human Services Impaired Driver Rehabilitation Weekend Program

12 King Philip Rd. Sudbury, MA (585)

School Based Oral Health Services

School Year

TRINITY DENTAL CLINIC Medical History Form Date:

Social Security Number: Employment Status: Employed Unemployed Address: Student Retired

COLON & RECTAL SURGERY, INC.

New Patient Registration Form. Male Female

The Priority Care Center

Welcome to Optimum Chiropractic & Wellness Center To The NEW PATIENT Outline of Procedures for Care And Consent to Initiate Care

If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5.

NEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone. Address: Driver s License #:

Registration Form Parent/Guardian Information:

Thank you, in advance, for being a partner in your care.

HEALTH HISTORY QUESTIONNAIRE

Dr. Ian C. MacIntyre

Transcription:

Date 3516 12th Ave NE * Olympia, WA 98506 * 360-456-1600 PATIENTS INFORMATION: First name MI Last name Date of birth M/F Street/PO Box City State Zip Home phone number Other Children (seen as patients): Parent or Guardian information: (Living in same household as patient) Relationship to patient: First Name MI Last Name SS# Street/PO Box City State Zip Home number Work number Cell number IS THE ABOVE ADDRESS THE CORRECT ONE FOR STATEMENT BILLING? Yes No

Parent or Guardian information (other contact): Relationship to patient: First Name MI Last Name SS# Street/PO Box City State Zip Home number Work number Cell number IS THE ABOVE ADDRESS THE CORRECT ONE FOR STATEMENT BILLING? Yes No INSURANCE INFORMATION: Primary Insurance: Name of Plan Subscriber ID# Group# Effective date Subscribers name Employer Subscriber s relationship to patient: Mother Father Self Other (explain): Secondary Insurance: Name of Plan Subscriber ID# Group# Effective date Subscribers name Employer Subscriber s relationship to patient: Mother Father Self Other (explain): Emergency Contact Information: (Relative/friend outside of the household) First name Last name Contact number Relationship to patient **Contact information will remain in place until changed in writing by you** Authorization for treatment of a minor: I,, the parent/legal guardian of, hereby authorize the physicians of Pediatric Associates to provide medical care to the above name minor child. _ Signature Date Relationship to patient Financial responsibility, Release of Information and Assignment of Benefits: I hereby authorize release of information necessary to file a claim with my insurance company, and assign benefits otherwise payable to me to the doctor or group indicates on the claim. I understand I am financially responsible for any balance not covered by my insurance company. A copy of this signature if just as valid as the original. _ Signature Date Relationship to patient

Date PARENTAL ADVANCE CONSENT TO TREAT MINORS Authorization for Pediatric Associates: I hereby authorize and consent to routine and emergency medical treatment for my child by qualified medical personnel at Pediatric Associates. I authorize and consent to emergency medical treatment when deemed necessary or advisable to safeguard my child s immediate health, and I cannot be reached within a reasonable time by reason of absence for the community or otherwise. I waive my right to informed consent to such treatment with the understanding what every attempt to contact me has been made. Signature Printed name Relationship to patient Date Other Authorization: This is to certify that the person(s) (not parents) listed below has my permission to authorize necessary medical care for my child, in the event that I am unable to accompany my child to their doctor s appointment. This authorization will be in effect until revoked in writing by me. I accept financial responsibility for necessary treatment and services. Name Relationship to patient Phone number Name Relationship to patient Phone number Does the above named person(s) have permission to speak with Pediatric Associates over the phone regarding your child s health care information? Yes No Signature Printed name Relationship to patient Date

Date NOTICE OF PRIVACY PRACTICES Pediatric Associates has a responsibility to protect the privacy of your health care information and to provide a Notice of Privacy Practices that describes how your health care information may be used and disclosed, how you can access your health care information, and whom to contact if you have questions, concerns or complaints. We may change the Notice of Privacy Practices at any time, and you may contact Cindy Strandberg at (360) 456-1600 ext 104 to obtain a current copy of the Notice of Privacy Practices of to ask questions. By my signature below I acknowledge receipt of the Notice of Privacy Practice given to me by a representative of Pediatric Associates. Signature Printed name Relationship to patient Date For Office Use Only Office staff complete below: I have attempted to obtain the parents signature on this form, but was not able to obtain for the reason(s) listed below: Reasons: Date Staff member s signature

PEDIATRICS ASSOCIATES No-Show Policy Quality care for our patients is our priority. Please take a few minutes to review our no-show policy and sign at the bottom of the form. If you have any questions please let us know. Definition of a No-Show Appointment Pediatric Associates defines a No-show appointment as any scheduled appointment in which the patient either: Does not arrive to the appointment Impact of a No-Show Appointment No-show appointments have a significant negative impact on our practice and the healthcare we provide to our patients. When a patient no-shows a scheduled appointment it: Potentially jeopardizes the health of the no-showing patient Cancels with less than 24 hours notice Arrives more than 10 minutes late and is consequently unable to be seen Is denying appointments to other patients in need of care Disrupts patient flow and affects other families How to Avoid Getting a No-Show 1. Confirm your appointment 2. Arrive 5-10 minutes early 3. Give 24 hours notice to cancel appointment 1. Appointment Confirmation Pediatric Associates will attempt to contact you two business days before your scheduled appointment to confirm your visit. **Please remember confirmation calls are a courtesy, ultimately it is your responsibility to know your appointment date and time. ** 2. Always Arrive 5-10 Minutes Early When you schedule an office visit with us, we expect you to arrive at our practice 5-10 minutes prior to your scheduled visit. This allows time for you and our staff to address any insurance or billing questions and or to complete any necessary paperwork before the scheduled visit. 3. Give 24 Hours Notice if You Need to Cancel When you need to cancel or rebook a scheduled visit, we expect you to contact our office no later than 24 hours before the scheduled visit. This allows us a reasonable amount of time to determine the most appropriate way to reschedule your care as well as giving us the opportunity to rebook the now vacant appointment slot with another patient. If it is less than 24 hours before your appointment and something comes up, please give us the courtesy of a phone call. Consequences of No-Show Appointments If you miss 3 or more appointments within a year you may be dismissed from the clinic. 1. Patient dismissal is at the discretion of your medical provider 2. Only emergency medical treatment will be offered within the first 30 days of dismissal I I have read and understand the Pediatric Associates No-Show Policy as described above. Patient Signature Date

HEALTH QUESTIONNAIRE Please complete the following questions. Skip any that you can t answer or do not apply to your child. Past Medical History (check all that apply) Is your child on any medications? Yes No If yes please list medications Any allergies to medications or foods? Yes No If yes please list allergies including reaction type: Does your child have any chronic medical problems (asthma, allergies, diabetes, seizures etc.) Yes No If yes please list Has your child ever been hospitalized? Yes No If yes please explain Any past injuries or broken bones? Yes No If yes please explain

Health questionnaire cont. Is your child up to date on immunizations? Yes No Any previous reactions to immunizations? Yes No If yes please explain: Social history Is your child in daycare? Yes No Does anyone in your home smoke? Yes No Do you have pets at the home? Yes No If so what kind? Who lives at home with your child? Family history Does anyone in the immediate family (parents, siblings, maternal grandparents, paternal grandparents) have any of the following medical issues: (please circle) ADHD Depression Anxiety High blood pressure Learning Disability Autism Developmental Delay Anemia Cancer Kidney Disease Liver Disease Diabetes Allergies Asthma Hay fever Seizure Heart Disease at early age? (Under age 55) Substance abuse If you circled yes to any of the above please list the family member s relationship to your child: (example: hay fever maternal grandmother)

2024 © careersdocbox.com Privacy Policy | Terms of Service | Feedback