New Patient Intake Form

Phone: (336) 538-0089 Fax: (336) 538-0097 Burlington, NC 27253 New Patient Intake Form Provider: Dr. Martin DeFrancesco Melody Burr Lindsey Overton Patient Name: DOB: Marital Status: Single Married Divorced Separated Widowed Occupation: What is the main reason you are here today? What other concerns do you have for your provider? Name of primary care physician? Medical History Have you ever had or do you now have any of the following? Anxiety/Depression UTI/Kidney Infections Herpes Painful Periods Cancer (where) Heavy Periods Abnormal Pap Smear AIDS/HIV Painful Intercourse Heart Disease Diabetes DVT/Blood Clot GERD/Acid Reflux Congestive Heart Failure PMDD Hepatitis High Cholesterol High Blood Pressure Heart Attack Endometriosis Peptic Ulcer Disease Osteoporosis Kidney Disease Rheumatoid Arthritis Sleep Apnea Systemic Lupus Other (Specify below) None/Healthy Other: Surgical History Please check the types of surgery you have had and write the approximate year the surgery was performed. Angioplasty/Heart Appendix Back Ablation CABG/Hearth Bypass Surgery Carpal Tunnel R / L Cataract Surgery Gallbladder Colon/Bowel/Intestinal Gastric Bypass Hernia Hip Replacement R / L Leep Tubal Ligation Knee Replacement R / L Pacemaker Thyroid Tonsils/Anenoids Laparoscopy C-Section Hysterectomy Breast/Mastectomy R / L Ovary/Tube Bladder Kidney D&C Essure Other Encompass Womens Care New Patient Intake Form PAGE 1

Patient Name: OB History First day of last menstrual period: Number of Pregnancies: Number of living children: Full-term Deliveries: Pre-term Deliveries: Miscarriages: Abortions : Ectopic: Year: C/S or Vaginal: Birth Weight: Sex: Complications *If pregnant today are there cats in the home? *What was your weight prior to pregnancy? Family History What is present in your immediate family? Breast Cancer Endometrial Cancer Diabetes Colon Cancer Ovarian Cancer Osteoporosis Any male(s) less than 55 years old with stent, bypass surgery and/or heart attack Any Female(s) less than 55 years old with stent, bypass surgery and/or heart attack None Social History Smoking: No Yes: How many packs a day? Years Smoking? Quit (year) Alcohol: None Socially Occasionally Weekly Daily Illicit Drug: None In The Past Presently Use: Current Contraception Method: Currently Sexually Active: Are you interested in HIV or STD testing today? Allergies TO MEDICATIONS Aspirin Latex Sulfa Codeine Penicillin None Known Other (specify) Encompass Womens Care New Patient Intake Form PAGE 2

Patient Name: Medications Medication Dose Frequency Refills ImMunizations Flu shot: Yes No Date: / / Pneumonia: Yes No Date: / / HPV (9-26 y.o.) Yes No Date: / / Rubella: Yes No Date: / / Varicella: Yes No Date: / / Hepatitis B: Yes No Date: / / Shingles: Yes No Date: / / Tdap: Yes No Date: / / Preventive Procedures Please choose yes or no and date when procedure was preformed. Date Location Result DEXA Scan Yes No / / Colonoscopy Yes No / / Fasting Blood Sugar Yes No / / Fasting Lipids Profile Yes No / / Mammogram Yes No / / Pap Smear Yes No / / Vitals to be obtained by Nurse/CMA WT: HT: BP: Pulse: Temp: To the best of my knowledge, the information I have provided is accurate. Patient/Legal Guardian Signature Date Encompass Womens Care New Patient Intake Form PAGE 3

Phone: (336) 538-0089 Fax: (336) 538-0097 Burlington, NC 27253 New Patient Information Date: Patient First Name: Middle: Last: Date of Birth: Social Security Number: Gender: [ ] Male [ ] Female Address: Home Phone: Cell Phone: Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Other Race: [ ] American Indian/Alaskan Native [ ] Asian [ ] Black/African American [ ] Other Race [ ] Native Hawaiian/Other Pacific Islander [ ] White [ ] Decline to Answer Ethnicity: [ ] Hispanic or Latino [ ] Not Hispanic or Latino [ ] Decline to Answer Language: Email: Employer: Employer Phone: Primary Physician: Preferred Pharmacy (Name and City): Emergency Contact: Relationship to Patient: Emergency Contact Phone Number: Responsible Party (Guarantor) Information Relationship to Patient: [ ] Self [ ] Parent [ ] Other Last Name: First Name: Date of Birth: Address: Home Phone: Cell Phone:

Encompass Women s Care Burlington, NC 27215 HIPPA Policy I authorize Encompass Women s Care to discuss my confidential medical information and leave messages regarding my medical conditions with the following people, including leaving messages regarding appointments or medical information on my answering machine. I understand that if I do not receive expected information (e.g. results of medical tests) it is my responsibility to contact Encompass Women s Care. Print Name: Signature Date

ACCT#: Encompass Women s Care 1041 Kirkpatrick Rd., Suite 100 Burlington, NC 27215 DOB GENERAL CONSENT TO EXAMINATION Alamance Regional Physicians Care AUTHORIZATION FOR TREATMENT ASSIGNMENT OF BENEFITS RELEASE OF MEDICAL INFORMATION CONSENT TO EXAMINATION AND TREATMENT: Knowing that I have a condition requiring medical treatment, I do hereby voluntarily consent to routine diagnostic and therapeutic procedures and medical care by Alamance Regional Physicians Care, my physician, and their assistants and designees. I further understand that the practice of medicine is not an exact science and that no guarantees have been made to me as the results of the care and medical treatment which I hereby authorized. I further understand that I may be required to relinquish private accommodations in the event they are needed for isolation purposes. Please check one of the boxes below for minors: YES I authorize my minor child to present to appointments without an adult and authorize Encompass Women s Care to perform necessary services to my minor child which are deemed advisable by the physician, including vaccinations, whether or not any adult is present at the actual appointment. No I DO NOT authorize my minor child to present to appointments without an adult and I do not authorize Encompass Women s Care to perform necessary services to my minor child which are deemed advisable by the physician, including vaccinations, whether or not any adult is present at the actual appointment. RELEASE OF INFORMATION: I hereby authorize Alamance Regional Physicians Care to release to the Medicare Bureau, Health Care Financing Administration, or its Intermediaries or health insurers or carriers, any information about me needed for this claim, including medical information relating to my treatment. Only information needed for the purpose of processing any claim for payment of benefits may be released. I also authorize the release of medical and related information about my treatment to the Professional Review Organization responsible for reviewing the medical furnished by this institution. I also authorize the forwarding of copies of information from my medical records to accompany me on a transfer from this institution to another acute care hospital, intermediate care facility, skilled nursing home or nursing home as ordered by my physician. I authorize the release of copies of my medical record for this visit to my attending physician(s). I further authorize inspection of my medical record by the N.C. Department of Human Resources as specified in GS 130-9 (e) (1) and other relative legislation to insure this facility s compliance regarding licensure and certification. I have been further advised that I have the right to object in writing to such release and that my objection in writing may prohibit the inspection or release of my information. This authorization will expire two years from this date; however, I reserve the right to withdraw this authorization at any time. ASSIGNMENT OF INSURANCE BENEFITS: I hereby assign and authorize payment directly to Alamance Regional Physicians Care of the benefits payable for Physician service benefits otherwise payable to me including payment of medical benefits, including Medicaid, but not to exceed regular charges for these services. I understand that I am financially responsible to the physician for charges not covered by this assignment. DATE: DATE: WITNESS PATIENT/REPRESENTATIVE GUARANTEE OF PAYMENT: The patient agrees to pay and any undersigned guarantor hereby guarantees payment of all charges and expenses incurred for provider services. The guarantor is not relieved of his/her liability by an extension of time granted for the payment of these charges or expenses incurred, nor by the acceptance by the provider of a note of the patient or any third person. The guarantor waives homestead and all other exemptions. In the event legal action is necessary to collect the debt, patient guarantor, or any other parties responsible for payment of servers rendered shall be responsible for reasonable attorney fees at 15% of the outstanding balance pursuant to N.C.G.S. section 6-21.2 to the filing of any complain. In the event a Judgment is necessary to collect the debt, guarantor or any other parties responsible for payment of services rendered would be responsible for 18% interest from the date of the breach of payment to date of judgment. DATE: DATE: WITNESS PATIENT DATE: DATE: WITNESS PATIENT

This Privacy Notice Highlights tells how we may use and disclose medical information we have about you and how you can get that information. Our complete Notice of Privacy Practice is available nearby. Please refer to that Notice of Privacy Practice for additional information. YOUR RIGHTS USES AND DISCLOSURES SCOPE This notice applies to Cone Health, including all of its facilities and services, and to those who provide care through Cone Health. HOW TO REACH US YOUR CHOICES Privacy Notice Highlights As explained in our complete privacy notice, some of the ways we may use and share health information about you are: - For treatment, payment, business, and administrative activities. - To inform you about our health-related benefits and services. - To recommend other treatments and health-care providers. - For public health activities. For other proposed uses and disclosures, except as required or permitted by law, we will explain the use or disclosure and ask your permission as necessary. Unless you tell us otherwise, we may include your name, location, general condition and religious affiliation in our patient directory. This information may be released to people who ask for you by name. Unless you object, we may disclose medical information about you to a friend or family member who is involved in your medical care. Unless you object, we may use our professional judgment to disclose necessary information to an agency assisting in disaster relief. You have a right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, or at a mailing address other than your home address. Unless you object, we may disclose medical information to contact you as a reminder that you have an appointment for medical care. If you want to place restrictions on ANY information, you must request a restriction form from the person who handled your registration. You may: Review, copy and ask us to amend certain medical information we have about you. Ask us to deliver medical information to an alternate address. Ask us not to share your information with certain family members or friends. Ask us for a list of certain disclosures we have made of that information. For general information, please call (336) 832-7000. If you have questions or concerns about your privacy or care, call our Privacy Officer at (336) 832-7075 or the Office of Patient Experience at (336) 832-7090. The Privacy Officer may also be reached at privacy.officer@conehealth.com or write to: Privacy Officer, Audit and Compliance Services, Cone Health, 1200 N. Elm Street, Greensboro, NC 27401

Encompass Women s Care Burlington, NC 27215

Encompass Women s Care Burlington, NC 27215