Lynn Hutchins Psychiatric Nurse Practitioner, PLLC
|
|
|
- Alvin Short
- 5 years ago
- Views:
Transcription
1 We look forward to working with you and getting to know you! It is our goal to provide the best mental health care, as well as making your visits here pleasant, courteous and as efficient as possible. Our normal office hours are Monday through Thursday, 8:00 am to 5:00 pm. We are closed for lunch from noon until 1:00. Please remember to bring your current insurance cards and co-payments with you to your visit. All co-pays and deductibles are due at the time of service. Patients that do not bring their co-pay or insurance card will be rescheduled. If for some reason your account falls into collection for non-payment, you will be responsible for your outstanding balance and any additional collection agency fees. We accept Visa, MasterCard, and American Express for credit or debit and also accept cash or check. If a check is returned due to insufficient funds, a processing charge of $50.00 will be charged to your account for the returned check. Our office does charge a fee for completing medical forms and for personal record requests. $10.00 per page Personal record requests -.75 per page first 25 pages,.50 pages (minimum request of $10.00) Narrative summary/letter - $25.00-$ Forms/letters are done as a courtesy and may take up to 30 days to complete. If for any reason you are unable to make your scheduled appointment, please call our office at hours prior to your visit. Missed appointments without 24 hours advance notice will be charged $75.00, payable before patient's next visit. For prescription refills, please include the phone number of your pharmacy and your date of birth or call your pharmacy and they will contact our office. Please allow 24 hours for regular prescription refills and 48 hours for all stimulant (medication for ADHD) prescription refills. Stimulant prescriptions must be picked up at the office. You may contact our office with questions, concerns or prescription refills by calling or by ing us at contact@lynnhutchinspsych.com and all efforts will be made to respond by the end of the day or at least within 24 hours. Consent for External Prescription Check I hereby grant permission to view my prescription history from external sources. In case of psychiatric emergency after hours or on the weekends, please call or call 911 for transport to your nearest emergency room. No refills will be given after hours or on weekends. For non-emergent issues, we ask that you call during regular office hours; otherwise, there will be a $35.00 charge billed to you. Our web page, lynnhutchinspsych.com, is an easy way to stay updated on closings due to holidays, vacation, or inclement weather which is important to ensure refills are prescribed to prevent running out of medication when the office is closed for extended periods of time. Please note that the office is always closed for a week during the Fourth of July holiday and December 24 through January 1. Please make sure you have enough medication to last during these periods of time. If you do run out, your primary care provider may or may not refill the medication until the office re-opens. Once again, welcome to. We look forward to establishing a lasting relationship as your mental health provider. Patient Name: Signature: Date: Witness: Patient Copy
2 We look forward to working with you and getting to know you! It is our goal to provide the best mental health care, as well as making your visits here pleasant, courteous and as efficient as possible. Our normal office hours are Monday through Thursday, 8:00 am to 5:00 pm. We are closed for lunch from noon until 1:00. Please remember to bring your current insurance cards and co-payments with you to your visit. All co-pays and deductibles are due at the time of service. Patients that do not bring their co-pay or insurance card will be rescheduled. If for some reason your account falls into collection for non-payment, you will be responsible for your outstanding balance and any additional collection agency fees. We accept Visa, MasterCard, and American Express for credit or debit and also accept cash or check. If a check is returned due to insufficient funds, a processing charge of $50.00 will be charged to your account for the returned check. Our office does charge a fee for completing medical forms and for personal record requests. $10.00 per page Personal record requests -.75 per page first 25 pages,.50 pages (minimum request of $10.00) Narrative summary/letter - $25.00-$ Forms/letters are done as a courtesy and may take up to 30 days to complete. If for any reason you are unable to make your scheduled appointment, please call our office at hours prior to your visit. Missed appointments without 24 hours advance notice will be charged $75.00, payable before patient's next visit. For prescription refills, please include the phone number of your pharmacy and your date of birth or call your pharmacy and they will contact our office. Please allow 24 hours for regular prescription refills and 48 hours for all stimulant (medication for ADHD) prescription refills. Stimulant prescriptions must be picked up at the office. You may contact our office with questions, concerns or prescription refills by calling or by ing us at contact@lynnhutchinspsych.com and all efforts will be made to respond by the end of the day or at least within 24 hours. Consent for External Prescription Check I hereby grant permission to view my prescription history from external sources. In case of psychiatric emergency after hours or on the weekends, please call or call 911 for transport to your nearest emergency room. No refills will be given after hours or on weekends. For non-emergent issues, we ask that you call during regular office hours; otherwise, there will be a $35.00 charge billed to you. Our web page, lynnhutchinspsych.com, is an easy way to stay updated on closings due to holidays, vacation, or inclement weather which is important to ensure refills are prescribed to prevent running out of medication when the office is closed for extended periods of time. Please note that the office is always closed for a week during the Fourth of July holiday and December 24 through January 1. Please make sure you have enough medication to last during these periods of time. If you do run out, your primary care provider may or may not refill the medication until the office re-opens. Once again, welcome to. We look forward to establishing a lasting relationship as your mental health provider. Patient Name: Signature: Date: Witness: Office Copy
3 Patient Information Please Print Patient Name Date of Birth Gender M F Mailing Address City State Zip Home Phone Work Phone Cell Phone Preferred number for reminder call: (Circle one) Home Cell Work May we leave a message: Y N SSN Address Emergency Contact Phone Relationship School/ Employer Grade If Patient is not Responsible Party, who is responsible for payment? Name Mailing Address City State Zip Relationship Phone Policy Holder Name DOB / / Policy Holder Address Policy Holder s Relationship to the Patient Insurance Company Name Subscriber # Ins. Co. Mailing Address Group # City State Zip Pharmacy Name Phone Please remember that insurance is considered a method of reimbursing the patient for fees paid to the provider, but is usually not designed to pay the entire fee. Because insurance companies vary in the amount they will pay for various services, it is ultimately your responsibility to pay the portion of the bill not paid by your insurance company (unless otherwise restricted by law or agreement we might have with insurer). ALL CO-PAYS AND DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier of any other commercial insurance company, and original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. Signature Date
4 Health History Name: Date: Indicate (Y) for yes and (N) for no for the following: Have you recently had: Fever Weight Loss Blurred Vision Sore Throat Sinus Problems Chest Pain Palpitations Shortness of Breath Wheezing Asthma Diarrhea Abdominal Pain Urinary Problems Sexually Transmitted Disease Weakness Diabetes Bleeding Bruising Muscle Pain Heat-Cold Intolerance Seizures Dizziness Depression Anxiety Rash What is the reason/medical problem for your visit? How long have you had the problem? Does anything cause the problem or make it worse? What medication do you take now? Do you have any pain? Rate the pain 1-10 Signature of Patient
5 Notice of Privacy Practices I,, have read and understand the Privacy Practices of Lynn Hutchins Psychiatric Nurse Practitioner, PLLC. I am aware that if I don t cancel my appointment at least 24 hours ahead of time, I will be charged a fee of $ I authorize to provide medication management and psychotherapy as needed. I am giving my written consent for screening, treatment, evaluation, and medication. Date Patient Signature Witness Signature of Patient s Legal Representative A copy of privacy practices was made available for the patient to read, but a signature was unable to be obtained because: Patient refused to sign Emergency situation
6 Controlled Substance Contract Some of the medications commonly prescribed in this office are controlled substances and can be addictive, such as benzodiazepines (Klonopin, Xanax, Valium, Ativan) and stimulants (Adderall, Ritalin). It is important that these medications be used responsibly. I,, understand and voluntarily agree that (initial each statement after reviewing): I am responsible for my medicines. I will keep the medicine safe, secure and out of the reach of children. If the medicine or prescription is lost, stolen or is used up sooner than prescribed, I understand that it will not be replaced until it is due for refill (30 days from when last filled). I will take my medication as instructed and not change the way I take it without first talking to Lynn. I will not sell my medicine or share it with others. I will not call at night or on the weekends to ask for refills. I understand that refill requests will be made during office hours only. I will tell Lynn all other medicines that I take, and let her know if I have a prescription for a new controlled substance from another provider. I will only use one pharmacy to get my controlled medications filled. I agree to give a blood, saliva, and/or urine sample, if asked, to test for drug use. I understand that I may lose my right to treatment in this office if I break any part of this agreement. Patient Name: Signature: Date: Witness:
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 REGISTRATION
PATIENT REGISTRATION Last Name First Name Middle or Maiden Mailing Address City County State Zip Physical Address (if different) Telephone: Home( ) Cell ( ) Work ( ) Preferred Contact: Home Cell Text Message
Advanced Diabetes & Endocrine Medical Center, P.A.
PATIENT REGISTRATION FORM Primary Care Physician Referring Physician Patient s Name: (Last) (First) (Middle) Address: Marital Status: S / M / D / W City/State/Zip: Social Security: Male / Female Date of
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
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
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:
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.
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)
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
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:
SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120
SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120 You have been scheduled for an appointment with Dr. Nandi. At your earliest convenience, please
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
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
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
Patient Registration Form
Patient Registration Form PATIENT INFORMATION Please Print Last Name: First: M.I. Mailing Address: City: State: Zip Code: Date of Birth: Gender: M F Married Single Widowed Divorced Separated Partnered
Orthopaedic Specialists, P.L.L.C. PATIENT INFORMATION
Orthopaedic Specialists, P.L.L.C. PATIENT INFORMATION Date: Patient s Last Name First Middle Initial Home Phone No. Street Address City and State Zip Code Cell Phone No. Social Security No. DOB Age Sex
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
WELCOME TO OUR PRACTICE! We look forward to seeing you very soon.
WELCOME TO OUR PRACTICE! We are glad to welcome you to Park Avenue Oculoplastic Surgeons (PAOS) and Park Avenue Surgery Center (PASC). Enclosed are some materials which will acquaint you with our facilities,
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 /
Brian D. Haas, M.D., PL PATIENT INFORMATION
Brian D. Haas, M.D., PL PATIENT INFORMATION NAME: Last First M DATE: / / ADDRESS: Street City State Zip Code Married Single Widowed Divorced Social Security # Sex: M F Birthday: / / RACE: ETHNICITY: PRIMARY
Patient Registration Form This form is posted on our website
Patient Registration Form This form is posted on our website www.kidseyecare.net Caring For the Vision of Our Future Patient Last Name: First Name: Sex : Male / Female Date of Birth: SS #: - - Phone: (
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
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:
LOGO. Financial Policy
LOGO Financial Policy Please read this financial policy carefully. If you have any questions about this policy, a member of our office staff will be glad to assist you. 1. Payment for Services: Our office
Louis Arno, MD, FACP, FCCP Nehal L. Mehta, MD, FCCP, D,ABSM Prashant B. Patel, MD, MS
Dear Patient, Welcome to Respacare! We are sending you our Patient Information, History, Medication and HIPPA Privacy forms for you to fill out before your office visit. DUE TO HIGH PATIENT VOLUME, YOUR
PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604 Patient Registration Form Last Name First Name Middle Initial Sex: M F of Birth Address City State Zip Code Social
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
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
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
PATIENT REGISTARTION
PATIENT REGISTARTION Patient Name: Last First MI Address: City: State: Zip Code: Tel # (h): Tel # (w): Cell #: S.S. #: DOB: Age: Email address: Male: Female: Marital Status Spouse or Parent Name Race Preferred
Prefix Last First Middle Suffix. Maiden Gender SSN Marital Status Date of Birth
Prefix Last First Middle Suffix Maiden Gender SSN Marital Status Date of Birth Race Ethnicity Primary Language Address Line 1 Address Line 2 United States Zip City State Country Home Phone Cell Phone Work
Welcome to Family Tree Dental Care Midway Rd., Ste 106A Farmers Branch, TX 75244
Patient Information: Patient s Name: Address: City, Zip Code: Email address: Sex: M/F SSN: Date of Birth: Age: Marital Status: Home Phone: Cell Phone: Work Phone: Responsible for Account/Subscriber/Guardian
Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -
New Patient Forms Today s Date: Name (Last, First, MI): Date of Birth: Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): _ Home Phone: _ ( ) Cell Phone: _ ( ) Work Phone:
Please bring the medications you are currently taking. If you had x- rays made, please bring the films with you when you come to the office.
Dear Patient: We would like to take this opportunity to thank you for choosing our office for your urologic care and to welcome you to our office. We are pleased that you have chosen us to provide 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#:(
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:
Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
Delaware Heart & Vascular, P.A.
NEW PATIENT QUESTIONNAIRE Name: Age: Date: Reason(s) for your visit today:---------------------------- Other physicians you have seen: --------- --- - - ----- ------- Past History: (Please include all
2018 REGISTRATION FORM HIGHLIGHTED AREAS REQUIRED (Please Print Clearly)
PATIENT INFORMATION 2018 REGISTRATION FORM HIGHLIGHTED AREAS REQUIRED (Please Print Clearly) Patient s Full Name (as it appears on insurance card) Name you prefer to be called Email How did you hear about
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,
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS General Information Date: Patient Name: Date of Birth: Age: M.I. How would you like to be addressed by our office staff? Sex: Marital Status: Spouse
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
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Today's / / PATIENT INFORMATION Patient Name Last First Middle Mr Mrs Marital Status (circle) Miss Ms Single/ Married / Divorced /Sep/ Widow Is this your legal name? If not, what
Other Scan(s): List All Your Medical Diagnosis: Chemotherapy? YES NO If yes, please list treatment regimen:
Patient Name: Today s Date: Preferred Language: Date of Birth: Age: SSN: Race: Ethnicity: Home Phone: Cell Phone: Work Phone: Best contact phone number should we need to reach you about your treatment:
TEXAS MEDICAL & SLEEP SPECIALISTS, PLLC REGISTRATION FORM ADULT
TEXAS MEDICAL & SLEEP SPECIALISTS, PLLC REGISTRATION FORM ADULT Referring Physician: Primary Care Physician: Patient s LEGAL Last name: First: Middle Initial: Patient Date of birth / / Marital Status:
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?
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:
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 /
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
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS General Information Date: Patient Name: Date of Birth: Age: M.I. How would you like to be addressed by our office staff? Sex: Marital Status: Spouse
EYES OF THE SOUTHWEST New Patient Information
EYES OF THE SOUTHWEST---------------------New Patient Information PERSONAL INFORMATION (Please Print) Name Date Date of Birth / / Age M/F MailingAddress Street /PO Box City State Zip Code E-MAIL ADDRESS
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
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
ADULT PATIENT REGISTRATION
PATIENT NAME: (LAST) (FIRST) (M) CELL: ( ) HOME: ( ) PERSONAL E-MAIL: (FOR PATIENT PORTAL) DATE OF BIRTH: / / AGE: GENDER: MALE FEMALE SOCIAL SECURITY: - - MARITIAL STATUS: SINGLE MARRIED WIDOW(ER) OTHER
Patient Name: Please list your medications below. Include the strength and how often you take them.
Orthopedic Surgery & Sports Medicine Douglas Dodson, DO, FICS Eric Freeh, DO, FAOAO Interventional Pain Management John V. Watkins, MD Foot, Ankle & Lower Leg Reconstructive Surgery John Anderson, DPM,
ERIC ROCKMORE, DPM, FACFAS
Date: Name Date of Birth Address City State Zip Code Email Address Preferred Language Social Security(Medicaid only) Referred by Gender Race Ethnicity Home# ( ) Work # ( ) Cell ( ) Preferred phone # (
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
We are limited, not by our abilities, but by our vision.
We are limited, not by our abilities, but by our vision. WELCOME Thank you for choosing Advanced Eye Care Center as your eye healthcare provider! On behalf of Dr. Lawrence Shafron, Dr. Rodgers Eckhart,
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:
TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: _ Primary Care Physician: _
TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: Primary Care Physician: Patient s LEGAL Last name: First: Middle Initial: Patient date
PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Last Name First Name Address City, State, Zip Email Address Home Phone Work Phone Cell Phone SS# Date of Birth Age Sex ( ) Male ( ) Female Marital Status (check one):
West Cary Family Physicians 256 Towne Village Dr Cary, NC
New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s
Welcome to Savannah Psychiatry
Welcome to Savannah Psychiatry We would like to welcome you to our office and help familiarize you with our office policies and procedures. If you have any questions, our office staff is available to assist.
Welcome and Thank You For Choosing Pain Specialists of Charleston, P.A.
Dr. Edward M. Tavel 2791 Tricom Street Charleston, SC 29406 Office: 843-818-1181 Welcome and Thank You For Choosing Pain Specialists of Charleston, P.A. Our mission is to further advance and promote the
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received a copy of CPP s Notice of Privacy Practices. The Notice
Past Medical History
Past Medical History Patient Name Age: Sex: M or F Allergies:_ of Birth Current Medicines: If Newborn: Was baby born in a Hospital: Y N If Yes what Hospital: Medical History BIRTH HISTORY (Please list
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
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
Today s Date (mm/dd/yyyy):
115 Christopher Columbus Drive, Suite 301 Jersey City, New Jersey 07302 201-706-3808 http://www.drsmedicalassociates.com/ WELCOME TO DRS MEDICAL ASSOCIATES LLC. PLEASE COMPLETE THE FORM LEGIBLY AND ENTER
Any pertinent medical records
Hello, and welcome to Arizona Pulmonary Specialists, Ltd. You are scheduled to see on at. Please plan to arrive 20 minutes prior to this time. If you are unable to keep this appointment for any reason,
BIRCH BAY DERMATOLOGY
BIRCH BAY DERMATOLOGY PATIENT INFORMATION Photo ID (State or Federal) Please provide this to the receptionist PATIENT REGISTRATION FORM By providing your contact information below, you are granting permission
Jamie Gottlieb, M.D. Spinal Surgery PATIENT INFORMATION
Jamie Gottlieb, M.D. Spinal Surgery PATIENT INFORMATION Patient name (please print) Date Date of birth Age Gender: Male Female We know that filling out these forms can be difficult, but please complete
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA Poonam Singh, M.D. * Elizabeth Sanchez Fowler, M.D. * Tonya Suffridge, M.D. * Anuradha Venkatachalam, M.D. Balbir Singh,
Patient Registration
Patient Registration First Name: Middle Initial: Last Name: Address: City: State / Zip: Responsible Party (for patients under 18): Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security Number:
Our office is located at 501 Darby Creek Road, Suite 21 in Lexington. This is just off Man- O-War Blvd, between Palumbo Drive and Mapleleaf.
COMPLETE, SIGN AND RETURN THIS ENTIRE PACKET OF INFORMATION PLEASE MAIL TO OFFICE AFTER COMPLETION DO NOT FAX Our office is located at 501 Darby Creek Road, Suite 21 in Lexington. This is just off Man-
Review of Systems (Please check all that apply)
Patient Name Birthdate Review of Systems (Please check all that apply) Constitutional Respiratory Skin Fever/chills Cough Rash Excess weight loss/gain Wheezing Diaper rash Loss of appetite Chest tightness
I have read and acknowledge all of the above policies associated with Pioneer Cardiovascular Consultants, PC including: (PLEASE INITIAL)
PH:(480) 345-0034; F:(480)345-4033 Patient s Name (Last) (First) (M.I.) SS# Date of Birth / / Marital Status Sex Race :( optional) Ethnicity: (optional) Preferred language: Referring Physician: _ Phone#:
Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N
Chief Complaint Form: Patient Name: Date: First MI Last Preferred Name Age: DOB: Occupation: Employer: Send Note? Referring Physician: Town: Y N Primary Care Physician: Town: Y N Coach/ Trainer/ Team Doctor:
***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
Social Security No: Home Phone: _. Employer: Work Phone: _. Employer Address: Occupation: _. Spouse/Parent Name: Phone No: _
THE NATIONAL RETINA INSTITUTE LEADERS IN THE TREATMENT OF RETINAL DISEASES Patient Information Form Patient Name: Date of Birth: -,--I _----'--/ Age: Social Security No: Home Phone: _ Street Address: --------------------------------------
SATISH NARAYAN, MD & NISHA SATISH, MD
Patient Registration Satish Narayan, MD Nisha Satish, MD Humaira Khalid, MD Vivian Kisanga, NP Dominique Wilson, NP : / / Acct. # Patient Name: Last First Middle Initial Preferred Name (nickname) SS#:
7541 US HWY 87 E, Suite #1 San Antonio, Texas (210) PATIENT S EMPLOYER PLEASE CIRCLE ONE :
7541 US HWY 87 E, Suite #1 San Antonio, Texas 78263 (210) 648-9900 PATIENT S EMPLOYER PLEASE CIRCLE ONE : PPO POS HMO HRA HSA CHOICE PLUSE HEALTH SELECT OTHER NOTICE OF PRIVACY I have reviewed Beaver
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with
TEXAS PEDIATRIC SPECIALTIES AND FAMILY SLEEP CENTER REGISTRATION FORM ADULT
Referring Physician: TEXAS PEDIATRIC SPECIALTIES AND FAMILY SLEEP CENTER REGISTRATION FORM ADULT Primary Care Physician: Patient s LEGAL Last name: First: Middle Initial: Patient Date of birth / / Marital
OUR POLICIES. Prior Authorization for prescriptions is $10.00 for each authorization completed.
OUR POLICIES Effective April 1, 2008, due to continued decreasing insurance reimbursements, we will begin strictly enforcing fees for certain tasks that we perform on behalf of our patients. Phone calls
PRIMARY INSURANCE: Policy # Group # Name of Subscriber (if other than patient)
MRN: (Office Use Only) PATIENT INFORMATION Social Security #: - - Last Name: First Name: MI: Address: City: State: Zip: Home #: ( ) - Work #: ( ) - Cell #: ( ) - Sex: Male Female DOB: Email: Referring
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
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
PATIENT INTAKE AND MEDICAL INFORMATION
PATIENT INTAKE AND MEDICAL INFORMATION PATIENT INFORMATION: Todays Date: DOB: GENDER: M F SSN (required): Marital Status: Divorced Married Separated Single Widowed Address: City: State: Zip: Phone (H):
Anthem Hills Dental PATIENT INFORMATION
PATIENT INFORMATION Patient Name DOB Date Address City ST Zip Preferred Contact # Home # Cell # E-mail _ SSN Marital Status: S M Other Employer Type of Work Work # Business Address_ City ST Zip Emergency
Consent For Treatment
Consent For Treatment I hereby give my permission for Piedmont Neurology, LLC (the Practice) to provide diagnostic services and medical treatment. I permit the Practice to file for insurance benefits to
PATIENT REGISTRATION
Date: How did you hear about us? Name of previous dentist: PATIENT REGISTRATION PATIENT INFORMATION First Name: Last Name: Middle Initial Preferred Name: Birth Date: / / Age: Male Female Soc Sec: - - Address:
New Patient Registration Information
W E L L S P A N P A T I E N T I N F O R M A T I O N New Patient Registration Information Form 8026-mg R4/16 3038 INTELLIPRINT FINANCIAL POLICY WellSpan Medical Group wants to provide our community with
Name: Date of Birth: First Middle Last Residence: Street City Zip Code Home Phone Number Social Security: - -
Today s Date: Name: Date of Birth: Residence: Street City Zip Code Home Phone Number Social Security: - - e-mail: Employment: Position Employer Work Phone Number Marital Status: (Please Circle) Single
Essex-Hudson Urology
256 Broad Street Bloomfield, NJ 07003 Phone: 973-743-4450 Fax: 973-429-9076 Patient Information Essex-Hudson Urology 243 Chestnut Street Newark, NJ 07105 973-344-9133 973-344-9188 213 S. Frank E. Rodgers
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
CHIROPRACTIC 1 ST NEW PATIENT INFORMATION PATIENT INFORMATION
PATIENT INFORMATION INSURANCE INFORMATION Patient Name: : Address: Birthdate: Responsible for this account: Relationship to Patient: Insurance Co.: Group #: ID #: SS Number: Sex: M F Age: Employer/School:
Local Address: City State Zip. Permanent Address: City State Zip. Secondary Insurance Co: Insurance Phone: Policy #:
Patient Intake Form : Patient Name: (Last) (First) (M) Local Address: City State Zip Permanent Address: City State Zip Home Phone: Work Phone: Cell Phone: Birthdate: Age: Sex: M F Marital Status: Ethnicity:
GIVE US STRENGTH PHYSICAL THERAPY
GIVE US STRENGTH PHYSICAL THERAPY Thank you for choosing Give Us Strength Physical Therapy for your rehabilitation needs. PATIENT INFORMATION: Name (Last, First, Middle Initial): DOB: Social Security Number: