DETO UROLOG 2401 West Oak Street Ste. #102 Denton, Texas 76201 Phone: 940-387-2241 Fax: 940-380-1374 Acknowledgment of Review of otice of Privacy Practices I have reviewed this office s otice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. Signature of Patient or Personal Representative Date Print ame of Patient or Personal Representative Description of Personal Representative s Authority
DETO UROLOG 2401 West Oak Street Ste. #102 Denton, Texas 76201 Phone: 940-387-2241 Fax: 940-380-1374 ISTRUCTIOS FOR RELEASIG PROTECTED HEALTH IFORMATIO TEST RESULTS, ETC. Please check es or o OK TO GIVE TO M SPOUSE OK TO GIVE TO M PARET/CHILD OK TO LEAVE O ASWERIG MACHIE/VOICE MAIL EMERGEC COTACT PHOE UMBER SPEAK OL TO ME (If this box is checked yes -all other lines must be check no ) ES O ES O ES O ES O ES O SIGATURE (If patient is a minor, guardian must sign) PATIET S AME (PRITED) DATE
PATIET IFORMATIO FORM ame Address City/State Zip Code Home Ph ( ) Work Ph ( ) Date of Birth Cell Ph ( ) Email Preferred Contact: Home Cell Work Gender: Martial Status: Male Female Single Married Divorced Widowed Ethnicity: Primary Language: Caucasian Black Asian Hispanic Pacific Islander Other American Indian English Spanish French Other Social Security#_ Family Doctor Employer ame/retired/disabled Pharmacy ame and Location Do you have any known drug allergies? GUARDIA/RESPOSIBLE PART/ISURED S IFORMATIO ame Address/Phone# (if different) Male Female Date of Birth Social Security# Employer/Business ame Work Phone I consent to treatment necessary for the care of the patient indicated on this form. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and any other health plan to Denton Urology. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as any original. I understand that I am financially responsible for all charges, whether or not paid by the said insurance. Authorization is hereby granted to release information as may be necessary to process and complete my claim. I verify that the above demographic information is correct and that I have supplied a current insurance card for the filing of medical services rendered to me. I understand that failure to notify Denton Urology of any insurance coverage changes could result in the financial obligation to rest fully on myself regardless of any contract between the insurance company and Denton Urology. SignedDate How did you hear about our practice? Friend Patient Physician ellow Pages Internet Other
PATIET HISTOR FORM Patient s ame: Date: Past Medical, Family & Social History List all serious illnesses in your immediate family. (Example: diabetes. tuberculosis, breast cancer, heart disease, etc.,) Sister Brother _ Mother Father Grandmother Grand father List any personal past illness and/or surgeries and when they occurred. Illness or Surgery Date Do you smoke? es o Were you a former smoker? es o Do you drink? es o Do you have a history of non-prescription/illegal drug use? es o Do you exercise regularly? es o Age 65 or Older or Review of Systems Do you now or have you had any ongoing problems related to the following systems? Circle es or o. Constitutional Symptoms Integumentary Fever Chills Headache Skin rash Boils Persistent itch Eyes Blurred vision Double vision Pain Allergic/Immunologic Hay Fever Drug allergies eurological Tremors Dizzy spells umbness/tingling Endocrine Excessive thirst Too hot/cold Tired/sluggish Gastrointestinal Abdominal pain ausea/vomiting Indigestion/heartburn Musculoskeletal Joint pain eck pain Back pain Ear/ose/Throat/Mouth Ear infection Sore throat Sinus problem Genitourinary Urine retention Painful urination Urinary frequency Incontinence Respiratory Wheezing Frequent cough Shortness of breath Hematologic/Lymphatic Swollen glands Blood clotting problem Cardiovascular Chest pain Varicose veins High blood pressure Psychologic Are you generally satisfied with your life? Do you feel severely depressed? Have you considered suicide? OUR PRIMAR CARE PHSICIA IS: Physician Signature: Date:
MEDICATIO LIST Patient ame: Date of Birth: Drug ame Strength Dosage Please list any medication allergies: