Hampton Roads ENT-Allergy 2018
|
|
|
- Randall Boyd
- 5 years ago
- Views:
Transcription
1 Hampton Roads ENT-Allergy 2018 Welcome to our practice. The information you provide below will be used to file insurance claims, expedite your care and contact the individuals pertinent to your care. Please complete all information. If information does not apply, write N/A. Please print clearly. Patient Information 2018 Last Name: First Name: MI: SSN: D.O.B: Sex: Marital Status: S M D W Sep Race: White / Black/ Hispanic / Asian / Other Address: Street City, State Zip Code Home Phone: ( ) - Cell Phone: ( ) - How did you hear about our office? Google Facebook Family/Friend Other Patient is: Full Time Student Employed Part-Time Retired Self Employed Employer: Work Number: ( ) Occupation Spouse's Name: Spouse's SSN: Spouses D.O.B: Can we leave messages at your home? YES NO Can we leave messages at your work? YES NO Responsible Party Information (If adult, put SELF and go to next section) Name: SSN: D.O.B: Relationship to Patient: Home Phone:( ) Work:( ) Address: Street City, State Zip Code Employer: Occupation: Shift: Military Only: Active Retired Branch of Service Rank Name/Phone number of Emergency Contact: Name: Relationship Phone Number Patient's Family Doctor: Patient's Referring Doctor Insurance Information (Primary) Ins Co Name: Policy #: Group #: Policyholder's Name: Policyholder's D.O.B: Policyholder's SSN: Relationship to Insured: (Secondary) Ins Co Name: Policy #: Group #: Policyholder's Name: Policyholder's D.O.B: Policyholder's SSN: Relationship to Insured: Date: Chart Number:
2 Date: WHY ARE YOU SEEING THE DOCTOR TODAY? ADDITIONAL RELATED SYMPTOMS (please circle): GENERAL: FATIGUE, FEVER, CHILLS, NIGHT SWEATS, WEIGHT LOSS, WEIGHT GAIN HEAD/NECK: HEADACHES, NECK STIFFNESS, NECK MASS ( L / R / MIDLINE) EYES: CHANGE IN VISION, REDNESS, DRYNESS, BURNING, ITCHY/WATERY EARS: HEARING LOSS (L / R ), RINGING (L / R), ITCHING (L/ R), FULLNESS (L / R), DRAINAGE (L / R), PAIN (L / R), RECURRENT EAR INFECTIONS NOSE: CONGESTION, RUNNY NOSE, POST NASAL DRIP, SINUS PAIN, SINUS PRESSURE, NOSE BLEEDS (L / R), LOSS OF SMELL, RECURRENT SINUSITIS, SEASONAL ALLERGIES MOUTH/THROAT: ORAL ULCER / LESION / MASS, SORE TONGUE, DENTAL PAIN, DRY MOUTH, BAD BREATH, SORE THROAT, LUMP IN THROAT, TROUBLE SWALLOWING, HOARSENESS, SNORING, RECURRENT THROAT INFECTIONS LUNG: SHORTNESS OF BREATH, COUGH (DRY / PRODUCTIVE / CHRONIC), WHEEZING, COUGHING BLOOD CARDIAC: CHEST PAIN, IRREGULAR HEART BEAT, FAINTING GI: NAUSEA, VOMITING, CRAMPING, CONSTIPATION, DIARRHEA, HEARTBURN SKIN: RASH, HIVES, ITCHING, ABSCESS, LESION NEURO: TINGLING / NUMBNESS, SEIZURE, DEVELOPMENTAL DELAY, DIZZINESS / VERTIGO MUSCLE/JOINT: JOINT PAIN, MUSCLE CRAMPS ENDOCRINE: COLD / HOT INTOLERANCE, ENLARGED LYMPH NODES PSYCH: DEPRESSION, ANXIETY, DIFFICULTY SLEEPING HEMATOLOGY: EASY BRUISING, FREE BLEEDING, BLOOD CLOTS MEDICATIONS TRIED FOR CURRENT PROBLEM (please circle): ANTIHISTAMINE: ZYRTEC, ALLEGRA, XYZAL, CLARITIN, BENADRYL, CLARINEX LEUKOTRIENE: SINGULAIR, ZYFLO INTRANASAL ANTIHISTAMINE: ASTEPRO, ASTELIN, PATANASE, OMNARIS NASAL SPRAYS: NASONEX, NASACORT AQ, VERAMYST, RHINOCORT AQ, NASALCROM, AFRIN, NEOSYNEPHRINE, FLONASE MUCOLYTICS: MUCINEX, NASAL SALINE SPRAY, NEILMED SINUS RINSE COMBOS: ZYRTEC D, ALLEGRA D, CLARITIN D, CLARINEX D, SUDAFED, TYLENOL SINUS, TYLENOL ALLERGY ASTHMA: ALBUTEROL, PROVENTIL, VENTOLIN, ADVAIR, ASMANEX, PULMICORT, SPIRIVA, SERAVENT, FLOVENT ANTIBIOTICS: AMOXICILLIN, AUGMENTIN, AVELOX, BIAXIN, BACTRIM, CLINDAMYCIN, CECLOR, CEFZIL, ERYTHROMYCON, KEFLEX, LORABID, LEVAQUIN, OMNICEF, ROCEPHIN, TETRACYCLINE, VANCOMYCIN, Z-PAK ORAL STEROIDS: PREDNISONE, MEDROL, ORAPRED REFLUX MEDS: PRILOSEC/OMEPRAZOLE, NEXIUM, PROTONIX, ACIPHEX, KAPIDEX/DEXILANT, PREVACID, PEPCID/ZANTAC, TAGAMENT MIGRAINE MEDS: RELPAX, TREXIMET, IMITREX, TOPAMAX, ZATIDOR EYE DROPS: NASAREL, OPTIVAR, PATADAY, CROMOLYN EAR DROPS: ACETASOL, AURALGAN, CIPRODEX, CIPRO HC, DERMOTIC OIL, DEBROX, TIROXIN, OFLOXACIN, CLOTRIMAZOLE OTHER: PAST PERSONAL MEDICAL HISTORY (please circle): ACID REFLUX, ASTHMA, CANCER:, COPD, DIABETES, HEART MURMUR, HEART ATTACK, HEART FAILURE, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL, HIV, KIDNEY FAILURE, LIVER DISEASE, SLEEP APNEA, STOMACH ULCER, STROKE, THYROID DISORDER (HYPO / HYPER / NODULES), OTHER PAST SURGICAL HISTORY (please list):
3 Date: FAMILY MEDICAL HISTORY (please circle): ALLERGIES, ASTHMA, BLEEDING DISORDER, CANCER:, DIABETES, HEART DISEASE, HIV, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL, THYROID PROBLEMS, OTHER SOCIAL HISTORY: DO YOU SMOKE / CHEW TOBACCO (Circle which)? NO QUIT YEARS AGO YES : PACKS/DAY x YEARS DO YOU DRINK ALCOHOL? NO YES : DRINKS/DAY DO YOU USE ILLICIT DRUGS? NO YES IF SO, WHICH?: ARE YOU OR COULD YOU BE PREGNANT? (females only) NO YES BREASTFEEDING? NO YES MEDICATION ALLERGIES?: NO YES Please list: LATEX ALLERGY? NO YES OTHER ALLERGIES?: PREFERRED PHARMACY: PHONE: ADDRESS: PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (include over the counter medications, herbals, etc.) I am not currently taking any medications MEDICATION NAME DOSAGE/STRENGTH FREQUENCY REASON FOR TAKING
4 Hampton Roads Otolaryngology, PLLC (herein referred to as HROA) appreciates the confidence you have shown in choosing us to provide for your healthcare needs. Below are our general policies. Please review this information and sign where indicated. Patient Financial Policies I understand that it is my responsibility to provide HROA with current, accurate billing information at the time of check in and to notify HROA of any changes in this information. I understand that it is my responsibility to pay my co-pay at the time services are rendered. I understand that this is a contractual agreement that I have with my health plan and that HROA also has a contract agreement with my health plan to collect co-pays at the time of service. I understand that I will be billed for any amounts due by me including co-insurance amounts, co-payments and deductibles and that I have a financial responsibility to pay these amounts. I understand that insurance claims pending which exceed the agreed upon time limit for payment with respect to the term of my insurance company s contract with my provider are my responsibility. I understand that if any charges billed to me are still outstanding after 90 days from the date services were rendered, my account may be referred to a collection agency or an attorney for collection, unless other acceptable payment arrangements can be made. I agree to pay all costs of collection, including but not limited to, thirty five percent collection agency fees plus attorney fees and court costs. In the event my account is in default, I agree to pay interest at the rate of (18%) per annum from and after the date of treatment. I hereby waive the benefit of my homestead exemption as to this debt. I understand it is my responsibility to obtain a referral (if required by your insurance company). If this referral is not obtained, then all charges will be the responsibility of the guarantor. I understand there is a $50.00 fee for any check returned from my bank. I understand that if I do not cancel an appointment 24 hours prior to my scheduled appointment time, or if I do not show for my appointment, there may be a $50.00 fee. If I cancel/no show three appointments, I may be released from care. If I am released, I will be notified in writing by HROA. I have read the above policy regarding my financial responsibility to HROA for providing services to me or the above named patient. I authorize my insurer to pay any benefits directly to HROA, the full and entire amount of the bill incurred by me or the above named patient. Consent for Treatment & Authorization for Release of Information I hereby authorize HROA through its appropriate personnel, to perform or have performed upon me, or the above named patient appropriate assessment & treatment procedures. Upon assessment by the physician,an endoscope may be used in order to further evaluate the nasal or sinus cavity,which may result in an additional charge determined by your insurance plan. I understand that in the course of treatment, there is a possibility that HROA healthcare workers may become exposed to my blood or body fluids. State laws require a sample of my blood be tested for the presence of infectious diseases. The results of the tests will be released to me and the healthcare worker that was exposed. I further authorize HROA to release any & all medical information on myself or the above named patient to my insurance company to process my claim and hereby authorize a copy of my medical information be sent to my primary care physician as well as any attending or consulting practitioners.
5 Acknowledgement of Review of Notice of Privacy Practices And Marketing Option Selection Patient Name: Chart #: I have reviewed the Notice of Privacy Practices for this practice and received a copy for my records, if requested. I consent to release of my Protected Health Information for the purposes of treatment, payment, and healthcare operations (as defined in the Notice). I understand that any release of information beyond these three purposes or any other legally permitted release requires a separate authorization. We must allow you the opportunity to opt-out of receiving information from our practice regarding treatment options available to you and other services we offer now and in the future. We will never release your information to a third party outside the scope of our Privacy Practices as explained on the Notice. If you do not make a selection and sign below, we will assume that you have consented to receive this information from us. Please make a selection below: Yes, I would like to receive information regarding treatment options and other services provided by Hampton Roads Otolaryngology Associates, PLLC. No, I do not want information regarding treatment options and other services provided by Hampton Roads Otolaryngology Associates, PLLC. Authorization for Release of Medical Information I,, (patient s name) hereby authorize Hampton Roads Otolaryngology Associates, PLLC to release or discuss any of my medical information with the follow individuals: (We cannot discuss any medical information with other physicians unless noted on your patient information form or listed here) Please include any friends and family members you may authorize to have access to any of your information Name Relationship to Patient If you would like to set limitations on what medical information can be released to these individuals please list below what information we may provide. If you would like no limitations set then just write ALL. *Please note that this authorization will expire in 1 year. If you would like to set a particular expiration date for less than 1 year please specify: Patient / Legal Guardian SIGNATURE Relationship to Patient Date
PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT
PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT Last Name: First: M.I.: Sex: Age: Date of Birth / / Social Security # - - Race: Ethnicity: Language Spoken: If patient is child / under 18: Parent
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
Patient Information Last Name First Name Middle Initial
Patient Information Last Name First Name Middle Initial Street Address Apt# City State Zip Code Social Security # Home Phone Cell Phone Email D.O.B Sex(M/F) Occupation Relation to Insured Self Spouse Child
ROBERT H. OLIVER, M.D., PLLC Otolaryngology Head And Neck Surgery Otolaryngic Allergy Chart #
Chart # PATIENT INFORMATION Please Print, Complete Fully, And Return To The Front Desk Circle One: Mr. Mrs. Ms. Miss. Dr. Child Please Circle: Sex: Male Female Marital Status: S M Other Widowed Patient
ADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?
PAYMENT POLICY: Payment or partial payment is required on the day of visit.
Patient Information Date Patient Name (First) (M.I.) (Last) Date of Birth SSN Gender Male Female Transgender-Male Transgender-Female Marital Status Race Ethnicity Preferred Language Patient Address City
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail:
Ear, Nose & Throat Consultants Patient Medical Hx Form Name: Date: / / DOB: / / Age:
Ear, Nose & Throat Consultants Patient Medical Hx Form Name: Date: / / DOB: / / Age: Reason for today s visit: Medications (include Aspirin, vitamins and herbal remedies, birth control and over-the-counter
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided.
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided. Last Name: First Name: Primary Care Physician: Referring
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014 Patient name: Account# Ear, Nose and Throat Associates, PC, believes that in the interest of good health care practices,
PATIENT HEALTH HISTORY Date:
PATIENT HEALTH HISTORY Date: In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. Name (First, middle initial, Last) Home Phone
New Patient Packet Please print and complete the following 6 pages. Bring the completed forms to your scheduled appointment. Thank you!
New Patient Packet Please print and complete the following 6 pages. Bring the completed forms to your scheduled appointment. Thank you! Washington Ear, Nose and Throat 80 Landings Drive, Suite 207 Washington,
Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D
PATIENT REGISTRATION FORM First Name: MI: Last Name: Date of Birth: Address: Apt#: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Work Phone ( ) SS#: - - SEX: Female Male E-mail Address: Ethnicity:
McMahan-Clemis Institute of Otolaryngology, SC Dr. John T. McMahan
McMahan-Clemis Institute of Otolaryngology, SC Dr. John T. McMahan Patient Registration PATIENT NAME DATE OF BIRTH ADDRESS CITY, STATE, ZIP HOME PHONE WORK PHONE CELL PHONE SOCIAL SECURITY NUMBER MARITAL
Patient Information Sheet PLEASE PRINT LEGIBLY AND COMPLETE ALL INFORMATION. Patient s Name: Nickname (if any): Address: City: State: Zip:
Patient Information Sheet PLEASE PRINT LEGIBLY AND COMPLETE ALL INFORMATION Today s : Patient s Name: Nickname (if any): Address: City: State: Zip: Phone ( primary number): Home:( ) Cell:( ) By providing
PATIENT REGISTRATION SOCIAL SECURITY NUMBER:
PATIENT REGISTRATION LAST NAME FIRST NAME MI M/F ADDRESS APT CITY STATE ZIP BIRTHDATE AGE MARITAL STATUS HOME PHONE SOCIAL SECURITY NUMBER: OCCUPATION: EMPLOYER NAME: WORK ADDRESS: WORK PHONE: PLEASE INDICATE
INFECTIOUS DISEASE TROPICAL MEDICINE & TRAVEL CLINIC
INFECTIOUS DISEASE TROPICAL MEDICINE & TRAVEL CLINIC HOW DID YOU HEAR ABOUT OUR OFFICE? DEMOGRAPHICS LAST NAME FIRST NAME MIDDLE INITIAL SOCIAL SECURITY NUMBER SEX PREFIX/SUFFIX DATE OF BIRTH (mm/dd/yy)
PATIENT INFORMATION PRIMARY INSURANCE INFORMATION
1001 Medical Plaza Dr. The Woodlands, TX 77380 www.woodlandsretina.com Tel: 281-367-9700 Fax: 281-367-9701 PATIENT INFORMATION Patient s Legal Name: Date of Today s Visit: Social Security # Date of Birth:
CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY
CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY Name Age Date of Birth Email _ Reason for today s visit Who referred you to this office _ Who is your primary care physician? Are you allergic
Chong S Kim, MD ENT and Facial Plastic Surgeon
Chong S Kim, MD ENT and Facial Plastic Surgeon 100 Commons Way, Suite 701 300 Perrine Rd., Suite 301 Holmdel, NJ 07733 Old Bridge, N.J 08857 Phone: 732-796-0182 Phone: 732-727-1355 Fax: 732-796-0186 Fax:
PATIENT INFORMATION FORM - DIABETES
PATIENT INFORMATION FORM - DIABETES PATIENT NAME: DATE OF BIRTH / / (mm/dd/yr) SOCIAL SECURITY NO - - ADDRESS HOME PHONE: ( ) CELL PHONE: ( ) WORK PHONE: ( ) EMPLOYER EMAIL: MARITAL STATUS S M W D SEP
Name Date of Birth / / First M.I. Last. Address City State Zip. Home Phone Cell Phone Work Phone. Address
3055 SOUTHWESTERN BLVD. 3500 SHERIDAN DR. ORCHARD PARK, NY 14227 AMHERST, NY 14226 (716) 675 2500 (716) 204 4263 PATIENT INFORMATION (Please Print) Today s Date: / / Name Date of Birth / / First M.I. Last
Anthony Sparano, M.D.
Anthony Sparano, M.D. Facial Plastic Surgeon Sparano Face & Nasal Institute NJ Institute for Robotic Hair Surgery Skin Sense Spa Patient : DOB: Date: Home Phone: ( ) Mobile Phone: ( ) E mail Address: Please
Name (Last, First, MI): Date of Birth: / /
Name (Last, First, MI): Address: Age: City: State: Zip: Sex: Male / Female Phone #: (Home): (Cell): (Work): Personal Email: Social Security #: Race: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Other
***PLEASE PRINT USING BLACK INK ONLY***
***PLEASE PRINT USING BLACK INK ONLY*** 100 Hospital Lane, Suite 220 Danville, IN 46122 HOME PHONE WORK PHONE CELL PHONE PHARMACY LOCATION PHONE # NAME SS# ADDRESS CITY STATE ZIP BIRTHDATE AGE HEIGHT WEIGHT
PRIMARY INSURANCE TO FILE SECONDARY INSURANCE TO FILE
Social Security #: Date: Full Name: Street Address: City: State: Zip: Mailing Address: City: State: Zip: Home Phone #: Employer/School: Employer Address: Date of Birth: Occupation: Work Phone #: Email:
CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.
PATIENT INFORMATION First Name: Middle Initial: Last Name: Mailing Address: Street Address: City: County: State: Zip: Phone #: Work: Ext: Would you like us to text you? Yes No Cell #: Driver s License
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Patient
RESPONSIBLE PARTY DEMOGRAPHIC INFORMATION
BRYAN LEATHERMAN, M.D. PATIENT DEMOGRAP H I C INFORMATION Last Name First Name Middle Preferred Name Maiden Prefix Suffix DOB Sex SSN Ethnicity Marital Status Driver s License # Primary Language English
PATIENT REGISTRATION FORM (Complete All Pages)
PATIENT REGISTRATION FORM (Complete All Pages) PATIENT NAME (Last) (First) (Middle Init.) STREET OR BOX NO. CITY STATE ZIP CODE HOME PHONEWORK #CELL #_EMAIL MARITAL STATUS: RACE/ETHNICITY : SOC. SEC. #
PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
Phone: (512) Fax: (512)
Phone: (512) 732 2774 Fax: (512) 329 6871 NEW PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Gender Single Married Widowed Divorced Address/City/State/Zip Email: Cell phone Occupation (if minor,
Date of Birth: Age: Social Security #: Address: City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div
Your Name: Email Address: Date of Birth: Age: Social Security #: Address: _ City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div Spouse s Name: Emergency Contact: Telephone
New Patient Packet. Thank you for choosing Shasta Regional Medical Group. Our office looks forward to serving you.
New Patient Packet Thank you for choosing Shasta Regional Medical Group. Our office looks forward to serving you. Prior to your appointment: Please complete the attached New Patient Paperwork. Be sure
Arizona Retina Associates
PATIENT INFORMATION PLEASE PRINT CLEARLY AND COMPLETE ENTIRE FORM Name FIRST MIDDLE INITIAL LAST SUFFIX (Jr., etc.) Address STREET CITY STATE ZIP Age Birthdate SS# Marital Status S M D W Sex M F Occupation
Birth Date: Age: Sex: Ethnicity: Carrier: Cardholder's Name: Carrier: Cardholder's Name:
Patient Information Patient's Last Name: First: MI: Social Security Number: Birth Date: Age: Sex: Ethnicity: Street Address: City: State: ZIP Code: Home Phone: Cell Phone: Work Phone: E-Mail Address: Referring
New Patient Medical Information Survey Revised 3/2013
New Patient Medical Information Survey Revised 3/2013 We are glad you chose the Augusta Surgical Group to meet your surgical needs. Please take a few minutes to fill out this form, as it will help us provide
PATIENT REGISTRATION FORM Account #:
PATIENT REGISTRATION FORM Account #: All forms must be completed and signed prior to treatment. GENERAL INFORMATION Patient Name: First Middle Last Address: Home Phone No: Work Phone No: Cell Phone No:
Marietta Podiatry Group Patient Registration Form
Marietta Podiatry Group Patient Registration Form CHART # 1. Patient Information (Please include all information as shown on insurance card.) Patient s Last Name Patient s First Name Date of Birth 2 Gender:
If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:
AMELIA A. PARÉ, M.D. PATIENT REGISTRATION Date of visit: PATIENT INFORMATION (PLEASE PRINT) Name: Date of Birth: Age: Male Female Race Social Security #: Marital Status: Single Married Divorced Widowed
NEW PATIENT INFORMATION Salutation First Name MI Last Name Nickname
NEW PATIENT INFORMATION Salutation First Name MI Last Name Nickname of Birth: Address: SSN: City: State: Zip: Home Phone: Daytime Phone: Mobile Phone: Which number do you prefer we use to contact you?
Patient Registration Form
Arizona Retina Institute Patient Registration Form Patientʼs Name:" " " " " " " Todayʼs Date:" /" / Patientʼs Social Security#" " " " " Date of Birth:" /" / Gender: Male " Female Marital Status: Single
Bellingham Arthritis & Rheumatology Center. 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F)
Bellingham Arthritis & Rheumatology Center 470 Birchwood Avenue, Suite C, Bellingham, WA 98225 (P) 360-734-5754 (F) 360-734-0586 Patient Name SSN Last First M.I. Date of Birth Age Sex: Male Female Address
Greater Austin Allergy, Asthma & Immunology
Greater Austin Allergy, Asthma & Immunology phone: (512) 732-2774 fax: (512) 329-6871 PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Sex Single Married Widowed Divorced Present Address City,
RESPONSIBLE PARTY (Complete only if patient is a minor or otherwise not financially responsible): Name: DOB: / / SSN: - -
Date / / Chart # PATIENT INFORMATION: Name: DOB: / / SSN: - - Address: Phone (H) ( ) - Gender: M F Phone (C) ( ) - Race: *OK to leave message with personal health information on voicemail of above phones:
Patient / Guarantor Information. Spouse / Parent / Other Information. Insurance. Date:
Patient / Guarantor Information Date: Patient's Legal Name: DOB: / / Address: City: ST: Zip: Home Phone: Cell Phone: Which phone number do you prefer we use? E-mail Address (Required for Patient Portal
VASCULAR HEART & LUNG ASSOCIATES
PATIENT INFORMATION Last Name: First Name: M.I: Address: City: State: ZIP: Telephone (Cell): (Home): (Circle preferred contact method). Email: Date of Birth (MM/DD/YEAR): / / Age: Sex: SS# Ethnicity [circle]:
Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
Wayne Foot & Ankle Center, P.A.
Patient last Name: First Name: Middle : Date of Birth: Age: SSN: Marital Status: Single: Married: Widowed: Divorced: Address: City: Zip code: Email Address: Home Phone # : Cell Phone #: Employer: Occupation:
ADULT PATIENT INFORMATION SHEET ENT & Audiology Center of Southlake 660 W. Southlake Blvd. Suite 100, Southlake TX (817)
ADULT PATIENT INFORMATION SHEET ENT & Audiology Center of Southlake 660 W. Southlake Blvd. Suite 100, Southlake TX 76092 (817) 416-9731 Date: Patient Name: (Last, First, Middle) DOB: SEX: PATIENT INFORMATION
VALLEY ENT ASSOCIATES, P.C.
VALLEY ENT ASSOCIATES, P.C. Patient Last Name: First Name: Middle Init: Date of Birth: Gender: Race: Social Security #: Street Address: City: State: Zip: Phone Number: Alternate Phone: Email: Parent /
Patient Profile. Gender: [ ] M [ ] F PATIENT INFORMATION. Date of Birth: Age: Name: SSN: Address: Marital Status: [ ] Married [ ] Single [ ] Other:
![Patient Profile. Gender: [ ] M [ ] F PATIENT INFORMATION. Date of Birth: Age: Name: SSN: Address: Marital Status: [ ] Married [ ] Single [ ] Other:](/thumbs/71/66129743.jpg "Patient Profile. Gender: [ ] M [ ] F PATIENT INFORMATION. Date of Birth: Age: Name: SSN: Address: Marital Status: [ ] Married [ ] Single [ ] Other:")
Patient Profile PATIENT INFORMATION Name: Address: City,State Zip: Alternate: Address City,State Zip: Home Phone: [ ] preferred Cell Phone: [ ] preferred Work Phone: [ ] preferred Is it ok for ValleyENT
Signature: Print Name: Date:
~ PLEASE PRINT CLEARLY ~ LAST ADDRESS FIRST MI HOME PHONE SOCIAL SECURITY # EMPLOYER WORK PHONE DATE OF BIRTH JOB/ PROFESSION: CELL PHONE MARITAL STATUS SPOUSE S SPOUSE S SOCIAL SECURITY # (If under spouse
PATIENT REGISTRATION FORMS
PATIENT REGISTRATION FORMS Last Name: First Name: Middle Initial: DOB: / / Street Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - SSN: - - Sex: M / F Email: (for patient portal purposes
New Patient Registration If patient is a minor, each parent to fill out a copy of this form. Patient Information
New Patient Registration If patient is a minor, each parent to fill out a copy of this form. Patient Information Last Name, First Name: Date of Birth: M / F SSN: Single / Married / Divorced / Widowed Email:
Patient Information. Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Address: Home Away Address: City: State: Zip:
Patient Information Date: Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Male Female Social Security #: Birth Date: / / Age: Local Phone: ( ) Cellular Phone: ( ) Email Address:
Surgical Group of Gainesville, PA
Surgical Group of Gainesville, PA REGISTRATION FORM Peter Sarantos, MD* FACS Bruce W. Brient, MD* FACS Stanley V. DeTurris, MD* FACS Brian E. Pickens, MD* FACS Timothy A. Hipp, MD* FACS Jeffery Jeffrey
Georgia Foot & Ankle
Georgia Foot & Ankle PLEASE PRINT CLEARLY Today s Date / / Name Date of birth / / First MI Last SSN Marital Status M S D W Age Weight Height Male Female Address City State Zip Phone (Home) (Work) (Cell)
New Patient Registration
Staff Use Only: PID#: Scanned by (Initials): Patient Arrival Time: AM / PM New Patient Registration Demographics Patient Information: Need help with Forms? Y N Preferred Language: English Spanish Other:
PATIENT INFORMATION. PATIENT NAME Last First M.I. Social Security Number. ADDRESS Street DATE OF BIRTH SEX Female Male
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Divorced
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S EMAIL: DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / /
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y. 14814 DATE: / / PATIENT INFORMATION FORM (PLEASE PRINT) PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX:
Anderson Office 8000 Five Mile Road #315 Cincinnati, Ohio (phone) (fax)
You have an appointment scheduled with Allergy & Asthma Care, Inc. at the following address: Anderson Office 8000 Five Mile Road #315 Cincinnati, Ohio 45230 (phone) 513.624.6600 (fax) 513.624.6722 You
REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:
Date: REGISTRATION FORM Physician (PCP): PATIENT INFORMATION Last Name: First Name: MI: Social Security #: DOB: Sex: M F Billing Address: City: ST Zip Code: Home Phone#:( ) Cell Phone#:( ) Work Phone#:(
Patient Information Form
ALASKA DIGESTIVE AND LIVER DISEASE, LLC Ronald J Boisen, M.D. Daryl M. McClendon, M.D. Jeffrey W. Molloy, M.D. Patient Information Form Patient s Name: Age: DOB: Sex: Male Female Marital Status: S M W
ADAMS HANOVER ENT, LLC JAMES A. MANNING, JR., M.D. BRET T. SOBOTA, M.D. JULEE A. EISENHART, C.R.N.P.
ADAMS HANOVER ENT, LLC JAMES A. MANNING, JR., M.D. BRET T. SOBOTA, M.D. JULEE A. EISENHART, C.R.N.P. 508 S. WASHINGTON STREET HILLSIDE MEDICAL CENTER GETTYSBURG, PA 17325 250 FAME AVENUE, SUITE 201 717-334-8171
Date: Medical History DOB:
Date: Medical History DOB: 1. Name: Age Right handed Left handed 2. Occupation: _ 3. Describe problem (be specific) 4. Duration of symptoms: 5. Date of Injury: Work Injury No Yes Dates you have been off
CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA (360)
CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA 98223-1668 (360) 435-6097 M.C. WHITMAN III, M.D., FACS PETER WOLFF, M.D., FACS DEAR You have been referred to Cascade Surgeons, the office of Dr. Whitman
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
ADDRESS: APT#: CITY: ZIP: IF ANOTHR PHYSICIAN, WHO?
ADULT DEPENDENT PATIENT INFORMATION SHEET ENT & AUDIOLOGY CENTER OF SOUTHLAKE PHONE: (817) 416-9731 FAX: (817) 416-9751 PATIENT NAME (LAST, FIRST, MIDDLE) AGE: SEX: ADDRESS: APT#: CITY: ZIP: PATIENT HOME
Patient s Full Legal Name: DOB: Sex: M F. SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip:
Patient Information: Date: Patient s Full Legal Name: DOB: Sex: M F SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip: Home Phone: Cell Phone: Daytime Phone: Email: Approved Communication:
HEALTH QUESTIONNAIRE NAME SEX AGE DOB HEIGHT WEIGHT PLACE OF BIRTH REASON FOR VISIT
HEALTH QUESTIONNAIRE NAME SEX AGE DOB HEIGHT WEIGHT PLACE OF BIRTH REASON FOR VISIT LIST OF MEDICATIONS: (IF ADDITIONAL SPACE IS NEEDED, PLEASE CONTINUE ON THE BACK OF THIS PAGE) DRUG DOSE FREQUENCY YEAR
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Patient Name: DOB: Address: ADDRESS CITY, STATE, ZIP SSN: Mailing Address: ADDRESS CITY, STATE, ZIP Same as above Home phone: Cell phone: Work phone: Marital Status: Single /
Endocrinology of the Rockies, PC. PATIENT REGISTRATION FORM E. 9th Ave. Ste. 245, Denver, CO 80220
1 PATIENT REGISTRATION FORM 2018 4545 E. 9th Ave. Ste. 245, Denver, CO 80220 Patient Name (Last, First, M.I.): Prefer to be called: Address: City: State: Zip: Home phone: ( ) Work phone: ( ) Day phone:
PATIENT INFORMATION. Date of Birth / / Patient s Age Male Female Marital Status S M D W
PATIENT INFORMATION Patient Name:Last First MI Date of Birth / / Patient s Age Male Female Marital Status S M D W Street Address City State Zip Code Home/Cell Phone Work Phone Email Address Social Security
PATIENT INFORMATION NOTICE OF PRIVACY POLICY PATIENT ACKNOWLEDGEMENT
PATIENT INFORMATION ( MR / MRS / MS / DR ) FIRST MIDDLE LAST DATE OF BIRTH AGE MARITAL STATUS (circle one) Married / Divorced / Single / Widowed STREET ADDRESS APT/LOT/ROOM/SUITE CITY STATE ZIP GENDER
about us? Birth Date Age SS# Marital Status (circle one) Single Married Widowed Divorced Spouse s Phone No. Spouse s Employer Race (optional)
Patient s Name Nickname Referring Physician Address Preferred Phone No. Sex (circle one) Male Female Patient s Employer City/State/Zip Alternate Phone No. Email How did you hear about us? Birth Date Age
Jason Guillot, MD James Connolly, MD Robert Owens, M.D. JJ Martinez, AuD Phone: Fax:
Phone: 985-327-5905 Fax: 985-327-5904 PATIENT INFORMATION DATE: Name: Gender: Male Female Last First Middle (Circle One) Date of Birth: Patient s SS#: Address: Street Address Apt # City State Zip Code
PATIENT QUESTIONNAIRE DATE OF VISIT: Pg. 1
PATIENT QUESTIONNAIRE DATE OF VISIT: Pg. 1 PATIENT NAME DATE OF BIRTH AGE PLEASE PROVIDE THE FOLLOWING MEDICAL INFORMATION TO THE BEST OF YOUR ABILITY: What problems are you here for today? List any allergies
Medical History. 12. List all previous Surgeries and Date of Procedure (Orthopedic or otherwise):
Date: Medical History DOB: 1. Name: Age o Right handed o Left handed 2. Occupation: 3. Describe problem (be specific): 4. Duration of symptoms: 5. Date of Injury: Work Injury: o No o Yes Dates you have
West Houston Infectious Disease Associates. Address: Number Street Apt. No. City State Zip. Home Phone: Cell: Work:
Carson T. Lo M.D. West Houston Infectious Disease Associates Linda S. Yancey, M.D. NEW PATIENT INFORMATION Thank you for choosing West Houston Infectious Disease Associates. Please completely fill out
Caritas Medical Center, LLC
Caritas Medical Center, LLC KIDNEY DISEASE AND HYPERTENSION SPECIALIST 105 NORTH PARK TRAIL SUITE 300 STOCKBRIDGE, GA 30281 OFFICE: 678 284 0800 FAX: 678 284 9299 WWW.CARITASMED.COM DR. LEO OVADJE DR.
. Assignment of Insurance Benefits
Pulmonary & Critical Care Associates, L.L.C. P l e a s e P r i n t Referred By: Dr. / Friend_ PATIENT INFORMATION (Name) City, State, & Zip:_ Number (home): EMPLOYMENT INFORMATION Employer: City, State
PATIENT HISTORY FORM. DOB: Age: Male Female Marital Status. Address: Preferred Method of Contact: Home Cell Work Text
PATIENT HISTORY FORM Name: SSN: (Last) (First) (MI) DOB: Age: Male Female Marital Status Address: (Street) (City) (State) (Zip) Home Phone: Cell: Work: Email Address: Preferred Method of Contact: Home
If you are employed, please provide the follow information regarding your employer; Employer Name: Work Address:
Personal Information Patient Registration Form Today s Date: Patients First Name: Date of Birth: / / Social Security #: - - Patients Last Name: Sex: Male / Female Marital Status: Married Single Divorced
EMERGENCY CONTACT INFORMATION PATIENT EMPLOYER INFORMATION GUARANTOR / POLICY HOLDER INFORMATION INSURANCE INFORMATION
Physician Name: Kyle F. Dickson, M.D. PATIENT DEMOGRAPHIC INFORMATION SHEET Last Name First Name Middle Social Security No. of Birth Age Male or Female (Please circle one) Marital Status: M S W D (Please
Patient Information. Emergency Contact Name: Pharmacy Information. Medical Release
Patient Information Patient's Last Name: First: Birth MI: Age: Social Security Number: Sex: Ethnicity: Street Address: City: State: ZIP Code: Home Phone: Cell Phone: Work Phone: E-Mail Address: Employer
Laguna Woods Dermatology
Laguna Woods Dermatology Patient Registration Form Visit date: Name: First Middle Last of Birth: Social Security Number: Nickname (optional): Sex: M F Address: Street City State Zip Mr. Mrs. Dr. Home Phone:
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX Phone: Fax: Address: City: ST: ZIP:
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX 75082 972-649-5937 Fax: 972-807-0385 Patients General Information Last Name: First Name: Patient s SSN: of Birth MM/DD/YYYY: / / Age: Sex: M/F
MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY
MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY Dear Patient, Thank you for choosing Michael K. Block, DPM, LLC for your podiatric needs. We value our relationship with you and would like to tell you
12319 N Mopac Expy, Bldg C, Suite #300, Austin, Tx (512) NEW PATIENT INFORMATION P L E A S E P R I N T
NEW PATIENT INFORMATION P L E A S E P R I N T Name: First Middle Last Date: Address: Street City State Zip ( ) ( ) ( ) / / - - Home Telephone Cell# Work Telephone: Patient Date of Birth AGE Patient SSN
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Widowed
Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS
WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions we ll be glad to help you. We look forward to
HIPAA PATIENT CONSENT FORM
HIPAA PATIENT CONSENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing
Patient Name: Last name First Name Middle Initial. Address: Street or Box City State Zip Phone: (Primary) (Cell) (Other) Date of Birth:
PATIENT REGISTRATION FORM Patient Name: Last name First Name Middle Initial Address: Street or Box City State Zip Phone: (Primary) (Cell) (Other) Date of Birth: Email: Gender: o Male o Female SSN# Marital
2014 Patient Information
2014 Patient Information Last Name: First Name: Date of Birth: Telephone #: Address: City, State, Zip: Employed Retired Disabled Employer: Telephone #: Primary Care Physician Name: Primary Care Physician
Buckland Ear, Nose & Throat, LLC. Medical History
Buckland Ear, Nose & Throat, LLC Medical History Patient Name: Today s Date: Primary Care Provider: Referred by: Pharmacy You Use: Date of Birth: Age: Name City 1. Reason for visit: 2. Past Medical History:
ADVANCED GASTROENTEROLOGY RESEARCH & ENDOSCOPY CENTERS
NEW PATIENT QUESTIONNAIRE Family Physician: Patient s Social Security #: (Social security number mandatory) Address: e-mail address: I understand that my e-mail will only be used for educational information.