PLEASE TAKE A MOMENT TO REGISTER FOR YOUR PATIENT PORTAL ACCOUNT.

Similar documents
SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely)

Welcome to Pinnacle Chiropractic Spine and Sports Center

Welcome to Pinnacle Chiropractic Spine and Sports Center

PATIENT INFORMATION SHEET:

DEMOGHRAPHICS INSURANCE INFORMATION

PATIENT REGISTRATION FORM

PATIENT INFORMATION INSURANCE INFORMATION

New Patient Registration Form NJR_NP_F100

Allergies Drug Food Environmental. Previous Surgeries & Hospitalizations (Please list date, reason, and hospital)

Age: Birthdate: Date of Last Physical exam:

PATIENT INFORMATION. Address: Sex: City: State: address: Cell Phone: Home Phone: Work Phone: address: Cell Phone:

Welcome to the Southeastern Urology Associates meridianemr Patient Portal

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country

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

Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician

WELCOME TO USF HEALTH

DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group

Bellevue Neurology PATIENT DEMOGRAPHIC FORM

Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with?

PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.

2200 Northern Boulevard, Suite 133 East Hills, NY Fax (516) Transitional Care

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

Your annual preventive visit, or complete physical exam, is scheduled with. Dr. on at AM/PM.

Thank you for choosing Southern WV Endocrinology. Enclosed you will find your new patient

Last Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone

Patient Communication Request

To All Mission Ranch Primary Care Patients:

Virginia Heartburn & Hernia Institute

NEW PATIENT WELCOME LETTER

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

Burton M. Sundin, M.D. / Reps B. Sundin, M.D. Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: address:

PATIENT INFORMATION. Patient s Name: Birthdate: ( ) F ( ) M LAST FIRST MI. ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed Occupation:

John L Ledbetter, M.D. Vince R. Forte, M.D. J. Hardy Gordon, M.D. Ronald L. Ellis, M.D.

Pediatric New Patient Form

Family Medicine Division. Nyree Bryant DO George R. Davis DO

PATIENT REGISTRATION FORM

Fulcrum Orthopaedics Patient Registration Packet

COLON & RECTAL SURGERY, INC.

M or F Patient s Date of Birth Patient s Social Security Number Sex. Secondary Address: (if have, Northern) Street City State Zip Code

MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB. Please answer the following questions about your current eye problems and medical history:

New Patient Registration Form. Male Female

DENTON UROLOGY 2401 West Oak Street Ste. #102 Denton, Texas Phone: Fax:

A Department of Adena Regional Medical Center 60 Capital Drive Chillicothe, OH (740) (740) WELCOME TO OUR CLINIC!

WELCOME TO OUR PRACTICE

Dear Patient, Sincerely, Gastroenterology Associates of North Jersey

PATIENT HEALTH QUESTIONNAIRE

Patients Name. Insurance policy holders name and Social security number. Address. Home Phone number. Work Phone Number

Welcome to Drexel Medicine!

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name

Entrance Case History (Please write or print clearly)

If you have health insurance, please bring your insurance card(s) so that we may verify eligibility and bill correctly.

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

NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:

TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP DATE OF BIRTH

ASSESSMENT / PATIENT SUMMARY

Integrative Therapies 7E Oak Branch Drive Greensboro, NC

James M. Wilson, M.D. - Medical Information to (fax to ) PATIENT INFORMATION Last name: First: D.O.

PATIENT REGISTRATION

May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female

Patient Registration Form

Patient Information: Last Name First Name MI. Address Apt/Room # City Zip. Community name (if not at home) Martial Status: S M W D

SPOUSE/GUARDIAN (If patient is married, give spouse information. If patient is a child, give parent information.)

Name (First): (MI) (Last) Date: Address: City: State: Zip: Home Phone: Cell Phone: Driver s License #: Driver s License State: Occupation:

NEW PATIENT INFORMATION Primary Care Physician

Family Medicine Division. Nyree Bryant DO George R. Davis DO

College of Sequoias Physical Therapist Assistant Program Student Health Release Form

New Patient Intake Questionnaire

Tennessee Neurology Specialists Affiliated with Baptist Healthcare Group

Thompson Medical Group New Patient Registration Form

Our office hours are Monday, Tuesday and Thursday, 7 a.m. to 7 p.m, Wednesday, 8 a.m. to 5 p.m. and Friday, 8 a.m. to 4 p.m.

Patient Demographic Sheet Chart # (clinic use only)

Sonas IMC, Inc. 555 S Camino Del Rio B2 Durango, CO Tel: Fax: New Patient Information Sheet (Please Print Clearly)

Patient Demographic Sheet

FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty

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

Patient Name First Middle Last Address Street City State Zip Home Phone Work Phone Cell Phone. Date of Birth SS#

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

Patient Name Date of Birth / / We need the following information in order to comply with federal regulatory standards, thank you.

Neck & Spine Patient Demographic

DIGESTIVE HEALTH CENTER Specialists who help you feel your best

University of Louisville Physicians in Family Medicine

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F

Norman H. Anderson M.D., P.A. Robert Boissoneault Oncology Institute INSURANCE AUTHORIZATION

THE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE

Patient Intake Form. Address City State and Zip

DAILY ACTIVITIES (Q1)

Fulcrum Orthopaedics Patient Registration Packet

Workers' Compensation Demographic Form. Patient Information

Would you like to follow us on: Twitter Facebook Physician's Signature

Workers Compensation Demographic

Patient Name: Last First Middle

PHONE: (813) FAX:

Thank you for choosing Pulmonary Associates. Welcome to our practice!

This Packet is ONLY for Nerve Pain Treatment Program with the ENR (Electro Nerve Regeneration)

Amarillo Bone & Joint Clinic. Welcome to Amarillo Bone & Joint Clinic,

Welcome to our practice!

HEALTH. CENTER Main St NE, Suite 101 PO Box 507 Duvall, WA ph fax Dr. Jeffrey P. Metcalf

Hawaii Family Physicians New Patient Information

Pamela Barton, MD Concierge Medical House Calls

Fax: Do not mail the forms!

Transcription:

PLEASE TAKE A MOMENT TO REGISTER FOR YOUR PATIENT PORTAL ACCOUNT. Following today s appointment your healthcare provider will communicate with you via your portal account. This will include: Viewing and keeping track of your medical information resulting from your visit Receiving important clinical reminders regarding your health care Receiving and viewing your lab and other test results You will also be able to: Request prescription refills from your health care provider Send non-urgent messages to our staff Request referrals Submit billing and insurance questions Schedule your own one problem appointment What to do: Best practice: complete the attached user agreement and return to a member of our staff today. We are happy to help you register while you are here today! Check the email account for the address you supplied to us within 24 hours for the registration link and instructions The registration link will expire within 72 hours so please activate promptly Let us know if you need assistance!

D. Andrew Macfarlan, MD Jane Shaw, MD Mark D. Niehaus, MD Mary Mary Whittemore, MD Deborah Campbell, MD Kimberly Carter, C-NP Kelly J. Maupin, FNP COMPLETE HEALTH MAINTENANCE EXAM APPOINTMENT CHECKLIST It is very important that you bring these completed forms on the day of your appointment so that these can be reviewed with you. If the forms are not complete prior to your appointment, you will need to do so prior to seeing the doctor which will take away from your actual exam time. We ask that you update these forms on a yearly basis. * For Morning Appointments: Nothing to eat or drink after midnight except water, black coffee or tea (no cream or sugar) in order to complete fasting blood work that may be ordered by your doctor. Be sure to take your regular medications with as much water as you need! * For Afternoon Appointments: We certainly understand if you are unable to fast for an afternoon appointment. We will be happy to schedule you to return for a morning appointment with a nurse should your doctor order fasting blood work during your exam. *Medications: If you are on medications, please bring them with you for review by your medical team and be sure to let us know of any refills you will require prior to your next visit. It is also important to let your doctor know of any medications prescribed for you by another health care professional. * For Women: If you are scheduled for a Pap Smear, please check your menstrual cycle on the calendar to ensure it will not interfere with your exam. If it does, please call our office to reschedule your appointment. *Missed Appointments: Please note: There will be a $25.00 fee for any appointment you do not keep without at least 24 hours notice of cancellation. *Arriving Late For An Appointment: We ask that you arrive 15 minutes prior to your appointment time. Should you arrive past your scheduled appointment time you may be asked to reschedule your appointment. Did you know due to changes in health care coding, when you are seen for your annual health maintenance exam (annual physical), you may still have a charge for this visit? *Insurance and Billing: Some insurance companies may refer to your yearly Health Maintenance Exam as a "routine physical, routine care and screening, or preventative health maintenance" and may have special benefit plans related to those type visits. You should familiarize yourself with your insurance company's coverage before your appointment to avoid billing surprises. For instance, should your doctor address chronic pre-existing problems or encounter a previously unaddressed problem while performing your yearly Health Maintenance Exam, your insurance company will be billed for this service rather than your being asked to schedule another appointment to address those issues. For patients with high deductible policies, health savings accounts, or other types of insurance policies, this may increase your out of pocket expense. Again, it is important to understand your coverage as well as what will be discussed with your health care provider. Your insurance company's telephone number is usually printed on the insurance card you carry. Or, if you have questions, please feel free to contact our office. Register for your Patient Portal Account.

ALBEMARLE SQUARE FAMILY HEALTHCARE D. Andrew Macfarlan, M.D. Mark D. Niehaus, M.D. - Deborah Campbell, M.D. - Jane Shaw, M.D. Mary Whittemore, M.D. Kelly Maupin, FNP Kimberly Carter, NP-C 416 Albemarle Square, Charlottesville, VA 22901 434-978-2126 Name of Patient: Date of Birth: _ Albemarle Square Family Healthcare is authorized to release protected health information about the above patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient's instructions. Entity to receive information. Check each person/entity that you approve to receive information. Description of information to be released. Check each box that can be given to person/entity on the left in the same section. Voicemail Results of lab tests/radiology. Phone # Other: Spouse (provide name and contact number) Financial All medical records Specific records Parent (provide name and contact number) Financial All medical records Other: Other (provide name and contact number) Financial All medical records Other: Patient information: I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient and may be updated each year. Signature of Patient or Personal Representative Date

Albemarle Square Family Healthcare Andy Macfarlan, M.D. - Mark Niehaus, M.D. - Jane Shaw, M.D. - Debbie Campbell, M.D. - Mary Whittemore, M.D. Kelly Maupin, F.N.P. - Kimberly Carter, NP-C 416 Albemarle Square Charlottesville, Virginia 22901 434-978-2126 Adult Review of Systems Name CONCERNS YOU WOULD LIKE TO DISCUSS DURING YOUR VISIT: DOB Date SYMPTOMS: Check symptoms you currently have or have regularly had in the past year. *Your health care provider will review this form with you* Constitutional Respiratory Skin Psychiatric Chills Fever Night sweats Feeling tired Weight gain Weight loss Eyes Eye pain Blurred vision Eyesight problems Eye discharge ENT Ear ache Loss of hearing Ringing in ears Nosebleeds Nasal discharge Mouth sores Sore throat Hoarseness Cardiovascular Chest pain Dizziness Palpitations Fast heart rate Large veins in legs Leg swelling Cough Wheezing Shortness of breath Trouble breathing w/exercise Trouble breathing w/lying flat Snoring Gastrointestinal Abdominal pain Nausea/Vomiting Constipation Diarrhea Heartburn Blood in stool Genitourinary Pain w/urination Incontinence Urination at night Blood in urine Frequent urination Muskuloskeletal Back pain Joint swelling Joint stiffness Joint pain Muscle Aches Skin lesions Rash Itching Change in a mole Neurological Dizziness Fainting Headaches Memory Loss Numbness Seizures Tremor Weakness Endocrine Heat/cold intolerance Hot flashes Increase in thirst Heme/Lymph Easy bleeding Easy bruising Swollen glands Please answer the following questions with a yes or no. In the past two weeks, have you felt little interest or pleasure in doing things? YES NO In the past two weeks, have you felt down, depressed, or hopeless? YES NO Do you feel safe in your current relationships? YES NO Have you had any threats by others to your health or safety in the last year? YES NO Have you had any significant life changes over the past year? If so, explain: Adult ROS 2017 Anxiety Sleep Problems Depression Change in personality Emotional problems MEN Only Erection difficulties Lump in testicle Sore on penis Discharge from penis WOMEN Only Breast lump Abnormal pap smear Irregular bleeding Severe cramps Pelvic pain Painful intercourse Absence of orgasm Vaginal discharge Nipple discharge Last period: Last pap smear (if done by GYN): Last mammogram(if done by GYN): Pregnant? Yes No Age onset menses? # of pregnancies: # of children: Surgeries in the past year:

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