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Welcome to our office Where did you hear about us? Yellow Pages (YP) Newspaper (NP) Website (WS) Friend or Family (FF) Physician Referral (PR) Other (OT) OFFICE USE ONLY Physician: Approved by: : NEW PATIENT INFORMATION (Complete if different from billing party) Name Address First Middle Last City State Country Zip Phone # ( ) Birthdate Sex M or F Race Marital Status S M W D Social Security # Employer Address of Employer Work Phone # May we contact you at work? Y N By E-Mail Y N E-Mail Address Emergency Contact Name Emerg. Phone # ( ) Relationship to billing party Guarantor/Responsible Party Name Address First Middle Last City State Zip Phone # Birthdate Sex M or F Marital Status S M W D Social Security # Driver's License # Place of employment Work Phone # OTHER INFORMATION Name and address of nearest relative not living with you Address City State Zip Phone # If you are currently under another physician's care, please list: Name Address City State Zip Whom may we thank for referring you to us? INSURANCE 1. Primary Insurance Company Name Group # Policy Member # Subscriber Name Subscriber Birthdate Sex M or F Social Security # Subscriber Employer and Address 2. Secondary/Supplemental Insurance Name Group # Policy/Member # Subscriber Name Subscriber Birthdate Sex M or F Social Security # Subscriber Employer and Address Please note whomever brings a child in to be seen is responsible for payment at time of service unless prior arrangements have been made. It is the custodial parent's responsibility to arrange reimbursement from a non-custodial parent. By signing below I hereby give my consent for Holston Medical Group to treat my minor child, under 18 years of age INSURANCE AUTHORIZATION AND ASSIGNMENT: I understand that I am financially responsible for any medical service at time of service. I authorize my insurance carrier to pay to Holston Medical Group any assigned claims filed by them and authorization for release of medical information requested by my insurance company. For Medicare beneficiaries: I request payment of authorized Medigap benefits be made to me or on my behalf to Holston Medical Group and medical information about me to be released to my Medigap insurer. Signature Rev. 10-2008

MRN: DATE RECEIVED: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing this document, I acknowledge that I have reviewed and/or received a copy of the Notice of Privacy Practices, which provides a more complete description of how my protected health information (PHI) may be used or disclosed. I understand that Holston Medical Group reserves the right to change their notice and information practices and that I may view a copy of the current Notice on Holston Medical Group s website, www.holstonmedicalgroup.com/hipaa, in any of their offices, or by a request in writing. I also understand that Holston Medical Group participates in the OnePartner Health Information Exchange (OnePartner HIE) and may make my medical information available electronically, or may electronically transmit my medical information to a third party, in order to fulfill provider obligations to release my medical information in the future. Print Patient Name Patient of Birth Patient Signature (if applicable) Authorized Representative Signature Relationship to Patient I understand that my protected health information will only be verbally communicated to those individuals listed below. Those individuals will be required to provide the last four (4) digits of my Social Security Number, along with my date-of-birth, before any information will be discussed with them. List the individuals that you want protected health information given to: FOR INTERNAL USE ONLY: Reason Acknowledgement Could Not Be Obtained: Employee Signature

NO SHOW POLICY Welcome to Holston Medical Group. Please take time to review the following information pertaining to our policy for no show appointments. We understand that scheduling conflicts occur from time to time. However, we request at least two hours advance notice if you are unable to keep your scheduled appointment(s). Two or more missed appointments may result in your family being dismissed from Holston Medical Group. Patients that fail to show up for a scheduled appointment may be charged a fee for not providing the office with prior notice of cancellation. Holston Medical Group physicians have developed our No Show policy in an effort to better serve our patients by providing same day appointments to those who are sick and need to be seen. If someone schedules an appointment and does not show for the visit, we have lost an available time that could have been used for a sick patient. We look forward to providing your health care needs. Your understanding and cooperation helps us to provide available appointments for patients who urgently need them. Please sign below as confirmation that you have read, acknowledge and understand our policy regarding no show appointments. Please Print Patient Name of Birth Account Number Please Sign Authorized Representative Relationship to Patient Witness HMG.550 Rev. 5-2012

Sapling Grove Pediatrics and Internal Medicine Name D.O.B. Address City State Zip Phone (Home) Phone (Work) Occupation Years at your job Marital Status Number of Children List your current exercise regimen Do you use any of the following (Please check and list approximate amount of usage): TOBACCO Currently use Amount used per day Use cigarettes Use Chewing Tobacco, Skoal, Snuff, Used in past but do not use now Number of years since used ALCOHOL Number of drinks per day DRUG ALLERGIES (Please list medication and the reaction) Please list approximate date of last vaccine for the following: Pneumonia Diphtheria Hepatitis Pertussis Measles Polio Mumps Tetanus Rubella Flu PERSONAL PAST MEDICAL AND SURGICAL HISTORY: (Please list approximate date and illness or surgery) LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING: (Please include over the counter medications and inhalers) HMG.SGPED.220 page 1

HEALTH MAINTENANCE INFORMATION (Please list date for the following) Female PAP Mammogram Male PSA Everyone Chest X-Ray EKG Colonoscopy or Flex. Sig. FAMILY MEDICAL HISTORY (Please list any blood relative who has suffered from any of the following - Please indicate which relative) Tuberculosis Stroke Migraine Headaches Mental Illness (Manic Depressive, Schizophrenia, Depression, etc.) Epilepsy Diabetes Cancer (List who and what type) Allergies Arthritis Gout Kidney Disease Glaucoma Osteoporosis Hypertension Heart Attack HMG.SGPED.220 page 2

MEDICAL HISTORY - Mark C for current or place and indicate the age when you had any of the following illness or disease: Main Problems (1) (2) Decreased Hearing Ringing in Ear Ear Infections Dizzy Spells Failing Vision Double or Blurred Vision Eye Pain Eye Infections - Frequent Nose Bleeds - Recurrent Sinus Trouble Sore Throat - Frequent Hay Fever / Allergies Hoarseness - Prolonged Pneumonia / Pleurisy Bronchitis / Chronic Cough Asthma / Wheezing Shortness of Breath on exertion lying flat Chest Pain High Blood Pressure Heart Murmur Palpitations Irregular Pulse Swollen Ankles Fainting Spells Chronic Fatigue Weight Loss - Recent Anem ia Bruise Easily Cancer Diabetes Convulsions / Seizures Tremors / Hands Shaking Numbness / Tingling Sensations Headaches - Frequent Back Pain - Frequent Gout Rashes Hives Psoriasis Eczema Sleeping Difficulty Nervousness Moodiness - Excessive Mental Illness Contact with Blood or Body Fluids Job Volunteer Leg Pain when Walking Varicose Veins / Phlebitis Loss of Appetite - Recent Difficulty Swallowing Indigestion or Heartburn Permanent Nausea / Vomiting Peptic Ulcer Abdominal Pain - Chronic Change in Bowel Habits - Recent Diarrhea Constipation Diverticulosis Bloody or Tarry Stools Hemorrhoids Gallbladder Trouble Jaundice / Hepatitis Hernia Urine Infections - Frequent Painful Urination Blood in Urine Overnight Urination - more than 2 Control in Urination Decrease in force of Urination Kidney Stones Venereal Disease Urethral Discharge Chicken Pox Pox Measles German Measles Rheumatic Fever Mumps Tuberculosis Thyroid Disease Stroke Muscle Weakness Arthritis / Rheumatism Bone Fracture / Joint Injury Foot Pain Cold Numb Feet Memory Loss Depression Phobias FEMALES: Onset age of Menses Regular Irregular Flow: Heavy Moderate Light Pain / Cramps with Menses Flow Days of Flow Length of Cycle of 1 st Day of Last Period Pain / Bleeding after Sex Number of Pregnancies Number of Live Births Number of Miscarriages Birth Control Method BC Pill Name Flushing / Menopause HMG.SGPED.220 page 3

ADVANCE DIRECTIVES What happens if you become too sick to make your own decisions regarding your medical care? Your family and doctor must decide what treatment to use; when not to treat, and/or when to stop treatment. Your family may not know what you would desire or may not agree on what would be best for you. It is best if they are aware of what you would desire and who you want to make those decisions on your behalf. With the enactment of a federal law, The Patient Self- Determination Act, you have the right to make decisions about your future health care. This includes the right to accept or refuse medical or surgical treatment and to plan and direct the types of health care you may receive if you become unable to express your wishes. You can exercise this right by making an Advance Directive. Different providers have, in accordance with state law, varying practices regarding the implementation of an Advance Directive. Information regarding such practices must be made available to you, upon request, when selecting or receiving care from the provider. If your physician, as a matter of conscience, is unable to comply with your directives, he/she must take all reasonable steps to arrange to transfer you to another physician. WHAT IS AN ADVANCE DIRECTIVE? An advance directive explains, in writing, your choices about the treatment you want or do not want, or about how health care decisions will be made for you if you are too ill to express your wishes. An advance directive expresses your personal wishes and is based upon your beliefs and values. When you make an advance directive, you will consider issues like dying, living as long as possible, being kept alive on machines, being independent, and the quality of your life. Use of an Advance Medical Directive makes it possible for your wishes to be carried out during a serious illness. If you are an adult and of sound mind, you can make an advance directive. There are two types of formal advance directives. You can complete a Living Will, a Power of Attorney for Health Care, or both. LIVING WILL A Living Will informs your physician that you want to die naturally if you develop an illness or injury that cannot be cured. It tells your physician that, when you are near death or in a vegetable state, he or she should not use life prolonging, measures which postpone, but do not prevent, death. POWER OR ATTORNEY FOR HEALTH CARE The Power or Attorney for health care is a form that you can complete to appoint another person (a health care agent ) to make health care decisions for you if you are not capable of making them yourself. MAINTAINING YOUR ADVANCE DIRECTIVE You should review and update your advance directive periodically. You have the right to change or discontinue your directive at any time. You should keep your advance directive in a safe place where you and others can easily find it. (Do not keep it in a safe deposit box) You should make sure your family members and your lawyer, if you have one, know you have made an advance directive and know where it is located. Be sure your physician has a copy of your advance directive in your medical file. Most states have specific rules as to what will be recognized as a valid advance directive. Below is an address for further information. DO ALL STATES RECOGNIZE MY DIRECTIVES? If you plan to spend time in a state other than your state of residence, from which you obtained your Advance Medical Directive, you may wish to execute advance directives in compliance with that state s laws as well. Specific questions should be directed to your physician and or attorney for guidance. Follow the instructions provided by your state when completing the Advance Directive forms. To obtain additional information, brochures, or forms you may write to the address below: Tennessee Commission on Aging Nashville, TN 37243-0860 Virginia Department for the Aging 1610 Forest Avenue, Suite 100, Richmond, VA 23229 I have read and understand the above: Name: Signature: of Birth: : MRN:

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