Fullerton Physical Therapy and Sports Care, Inc.

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

Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name

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

DRUG / MEDICATION ALLERGIES: (include: Type/Reaction)

Sage Medical Center New Patient Forms

351 Osborne Road, Loudonville, New York ARWynnykiwDDS. Welcome!

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

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

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

Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.

New Patient Registration Form NJR_NP_F100

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

GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP

R. B. KO L A C H A L A M M. D. GENERAL SURGERY

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

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

The Home Doctor. Registration Checklist

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

PATIENT REGISTRATION FORM Please Print

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

Tel: Fax:

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

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

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

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

NASSAU CHEST PHYSICIANS, PC PATIENT DEMOGRAPHIC FORM

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

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

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

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

Crescent Community Clinic Application for Healthcare Services

Julie Gussenhoven, OD 3416 Bechelli Lane Redding, CA 96002

Welcome to Fosston Chiropractic Clinic, P.A.

Lake Mary Eye Care Adult Form

Worker s Compensation Forms

Independent Wellness Center 1000 W. Apache Trail, Suite #108, Apache Junction, AZ Phone# Fax #

Statement of Financial Responsibility

MICHELE S. GREEN, M.D.

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

Patient s Name Home Phone # Last First Middle Would you like reminders sent here? Y N Cell # Address City State Zip

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

Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:

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

Virginia Heartburn & Hernia Institute

MARATHON PHYSICAL THERAPY & SPORTS MEDICINE. Canton Dedham Easton Newton Norton Norwood Pembroke

Body Basics Physical Therapy Medical History

City. Whom may we thank for referring you to us?

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

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

Welcome to our office! Please fill out this form as completely as possible and return it to the desk.

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

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

Patient Name Today s Date: Mailing Address Home Phone: City State Zip: Work Phone: Cell Phone: Birth Date: / / Age: SSN: Sex: Male Female

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.

Flossmoor: (708) Harvey: (708) Tinley Park: (708) ICOR: (708) Crestwood: (708) Patient Signature:

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

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

Use this kit to keep your loved one s medical and financial information organised in one central place. DOCTOR VISIT Worksheet

Welcome and thank you for choosing Jerman Family Dentistry

Revised 4/28/2015 Crescent Community Clinic Application for Healthcare Services

Rosati Family Chiropractic Intake Form

CURE CARDIOVASCULAR CONSULTANTS

Patient Name: First Middle Last Address: City: State: Zip Code: Date of Birth: Social Security: Marital Status: S M D W

Thank you for contacting the Saint Francis Center for Surgical Weight Loss.

Surgery Handbook. ! a GUIDE to PREPARING for your OPERATION Lincoln Circle SE Orange City, IA ochealthsystem.org

PATIENT INFORMATION (Please Print)

New Patient Paperwork

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION. ETHNICITY: (Please circle one) Hispanic or Latin, Not Hispanic or Latin, Refuse to Report

PATIENT INTAKE FORM. CONTACT US S. Broad Street Lansdale, PA PHONE FAX

DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group

ADULT PATIENT INFORMATION. Patient Name: Last Name First Name Address: City: State: Zip Code: Phone #: Cell Phone #: Social Security:

TRINITY DENTAL CLINIC Medical History Form Date:

DAHIYA FACIAL PLASTIC SURGERY AND LASER CENTER CONSULTATION AND MEDICAL HISTORY. Name Date of Birth Today s Date Address: Street City State Zip

Welcome to the office of JillAnne W. McCarty, MD, PhD. We are looking forward to meeting you.

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

PATIENT HISTORY. Name Last First Middle/Maiden Name you Prefer. Address Street City State/Zip. Address

COLON & RECTAL SURGERY, INC.

Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet

MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?

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

Age: Birthdate: Date of Last Physical exam:

Dear Patient, Sincerely, Gastroenterology Associates of North Jersey

Patient s Legal Name: Preferred Name: First Middle Last

Dear New Patient: Sincerely, The Scheduling Staff

Medical History. Patient Information. Dental History. Your current physical health is: Good Fair Poor

Welcome to the Southeastern Urology Associates meridianemr Patient Portal

PATIENT REGISTRATION FORM

2018 Health Observances & Recognition Days

Medications List. Allergies. Drug Name Dosage Directions Reason Taking

Seasons Women s Care Patient Registration Form

PATIENT DEMOGRAPHICS. Age: Date of Birth: S.S#:

Dear New Patient. Tarrant County Medical Institute values its patients and is committed to providing them with the highest of quality care.

Pediatric Patient History

Patient Information. Address: City: State: Zip: Spouse/Guardian s Last 4 Digits S.S. #: Phone: ( ) Cell Phone: ( ) Emergency Contact Information

Patient Questionnaire Please print clearly

PATIENT INFORMATION & CONDITION FORM

CASE REPORT FORM (CRF) Worksheets

The Providers and Staff of Baptist Medical Group Primary Care- LiveOak BAPTISTMEDICALGROUP.ORG. Primary Care - Live Oak.

PATIENT APPLICATION FOR TREATMENT

Transcription:

Fullerton Physical Therapy and Sports Care, Inc. Patient Information: Title Address Patient Name (Last, First, Middle initial) City/State/Zip Home Phone Work Phone Cell Phone Social Security DOB Gender Driver s License M F Email Address Referring Physician Marital Status Occupation Address Employer City/State/Zip Emergency Contract (Name) Home Phone Work Phone Have you had any other physical therapy or chiro services this year? Y N If so, how many visits? Have you had any home health care this year Y N Financially Responsib Party if Not Patient Name (Last, First, Middle initial) Address Relationship to Patient City/State/Zip Home Phone Work Phone Social Security DOB Sex M Inquiry Information Email Address F Driver s license Is condition surgery related? Is condition accident related? Describe Accident Date of surgery Was an automobile involved? Surgical Procedure Date of Accident Where you injured on the job? Date of Injury Name of employer at the time of accident? City/State/Zip Code Describe Injury Litigation Involved? Name of Attorney Phone

MEDICAL INFORMATION QUESTIONNAIRE IN ORDER TO EVALUATE YOUR CONDITION FULLY, THE FOLLOWING PATIENT HISTORY IS ESSENTIAL. PLEASE BE AS ACCURATE AS POSSIBLE. NAME (please Print) DATE PATIENT ILLNESS OR INJURY: FOR WHAT CONDITION OR SYMPTOM ARE WE SEEING YOU? WHEN DID THIS PROBLEM BEGIN? (Date) WHAT TREATMENT HAVE YOU ALREADY RECEIVED? HAVE YOU EVER HAD THIS PROBLEM IN THE PAST? PAST MEDICAL HISTORY: (PLEASE INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING CONDITIONS) ARE YOU PREGNANT DO YOU HAVE A PACEMAKER OSTEOPOROSIS FAMILY HISTORY: HAS ANY IMMEDIATE (BLOOD) RELATIVE HAD ANY OF THE FOLLOWING: (CIRCLE) ARTHRITIS DIABETS BLEEDING TENDENCY HEART DISEASE CANCER STROKE HEART DISEASE: ANGINA ANGIOPLASTY. ARRHYTMIA. ATHEROSCLEROTIC DISEASE (CAD). CONGESTIVE HEART FAILURE (CHF). CORONARY ARTERY BYPASS GRAFT (CABG). HEART ATTACK (Myocardial Infarction)-(MI).. HIGH BLOOD PRESSURE. STENTS... VALVULAR DISEASE... LUNG DISEASE ASTHMA..... EMPHYSEMA....... COPD....

VASCULAR DISEASE: ACQUIRED RESPIRATORY... BLEEDING or BLOOD DISORDERS............ CHRONIC BRONCHITIS...... DIABETES... DISTRESS SYMDROME (ARDS)... PERIPHERAL ARTERIAL DISEASE... STROKE/TIA... TAKING BLOOD PRESSURE MEDS... GENERAL MEDICAL CONDITIONS: ALLERGIES... ANXIETY OR PANIC DISORDER... ARTHRITIS (rheumatoid/osteoarthritis)... BACK PAIN (neck pain, lower back, degenerative disc disease, spinal stenosis)... CANCER/TUMOR... DEPRESSION... EPILEPSY or CONVULSIONS... GASTROINTESTINAL DISEASE (ulcer, hernia, reflux, bowel, liver, gall, bladder)... HEADACHES... HEARING IMPAIRMENT... HEPATITIS... HERNIAS... INCONTINANCE... PREVIOUS ACCIDENTS... KIDNEY, BLADDER, PROSTATE OR URINATIN PROBLEMS... NEUROLOGICAL DISEASE (such as MS or Parkinson s)... PRIOR SURGERY (S)... PHOSTHESIS/ SURGICAL IMPLANTS... SLEEP DYSFUNCTION... VISUAL IMPAIRMENT (such as cataracts, glaucoma, macular degeneration)... IF CHECKED, PLEASE DESCRIBE OTHER MEDICAL PROBLEM T LISTED? ALLERGIES: (CIRCLE) IODINE COMPOUNDS TAPE HEAT OIL COLD TALCUM POWDER OTHER: MEDICATIONS YOU RE CURRENTLY USING:

Important Info for All Medicare Patients Regarding Home Health Dear Medicare Patient, Please be advised that Medicare will not cover outpatient physical therapy if you are currently receiving home health care. Home Health Care means services provided by a licensed home health agency to an insured in his/her place of residence that is prescribed by the insured s attending physician as part of a written part of care. This can include ANY medical treatment that you receive in your home, such as nursing care, speech therapy, or chemotherapy, not just physical therapy. If you have received any home health services, it is imperative that the home health agency formally discharges you before you begin physical therapy in our office. Even if your home health care treatment has ended, Medicare will not cover physical therapy unless they have an official home care discharge date on file. Please contact your home health agency if you have received care at home in the recent past to ensure you have been completely discharged. If you have any questions, please stop by the billing department. We are here to provide the highest quality of patient care and are happy to help address any concerns you may have. I have read and understand the above information regarding Medicare s policy for home health care and outpatient physical therapy. Yes, I have had home health care. My last date of treatment at home was / /. I have or will contact my home health agency to make certain I was properly discharged. No, I have not had home health care. Patient Name: Patient Signature: Date: / /

TICE OF PRIVACY PRACTICES INFORMATION ABOUT YO MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 1. OUR PLEDGE REGARDING MEDICAL INFORMATION The privacy of our information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information. 2. OUR LEGAL DUTY Law Requires Us to: 1. Keep your medical information private. 2. Give you this notice describing our legal duties, privacy practices and your rights regarding your medical information. 3. Follow the terms of the current notice. We Have the Right to: 1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. 2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created and received before the changes. Notice of Change to Privacy Practices: 1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. 3. USE ANFD DISCLOSURE OF YOUR MEDICAL INFORMATION The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose

not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care you. We may also share medical information about you to your health care providers to assist them in treating you. FOR PAYMENT: We may use and disclose your medical information for payment purpose. A bill may be sent to or third-party payer. The information on or accompanying the bill may include your medical information. PRIVACY PRACTICES ACKWLEDGEMENT ACKWLEDGEMENT FORM Name Birth Date Signature Date Please Print Out This Form Set And Sign And Date Pages 5 and 7.

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