LERGIES (please list name of medication and what happened when you took it. I d codeine)
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- Gillian French
- 5 years ago
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1 NAME DATE OF BIRTH ADDRESS
2 LERGIES (please list name of medication and what happened when you took it. I d codeine)
3 Please complete all of the following questions Have you or any family members ever had trouble with: Myself Relative Relationship to you EYES: Visual Loss (one or both eyes) Dry eyes Itching or irritation of the eyes Blurred or double vision Crossed or lazy eyes Cornea problems Thyroid eye disease Wear glasses or contacts Previous eye or eyelids surgery If so please describe what type: NOSE: Difficulty breathing through nose Previous injury to nose Nasal Allergies Frequent nose bleeds Sinus problems Nasal Polyps Previous nasal or sinus surgery If so, please describe what type: FACE/HEAD: Irritation to the face or neck History of radiation for acne treatment Acne Vitiligo Keloid formation Previous face or neck surgery If so, please describe what type: CARDIOVASCULAR: Angina, or history of chest pain Heart murmur Mitral Valve Prolapse History of Heart Attack Congenital heart disease Palpitations or irregular heart beat Stroke High Blood Pressure CHEST: Shortness of breath Shortness of breath when exerting yourself Asthma Chronic lung disease Coughing up blood PSYCHIATRIC: Has there been any recent crisis in your life Do you have claustrophobia Have you ever been treated for drug or alcohol dependency Have you received psychiatric treatment If so, were you hospitalized:
4 OTHER: Ulcers or stomach problems Gallbladder trouble Seizures or convulsions Kidney problems or urinary tract infections History of tuberculosis Liver disorder: hepatitis or cirrhosis Spinal or back disorders Previous blood clots or thrombophlebitis Free bleeding or bleeding disorders History of blood transfusions Diabetes Autoimmune disease (Lupus, rheumatoid arthritis, etc.) If applicable, are you pregnant Please explain any YES answers here: Do you smoke? How much? Do you drink more than 6 cups of coffee per day? Do you usually drink two or more alcoholic drinks a day Have you been hospitalized for a medical illness? If so, for what reason: Have you ever had a positive blood test for HIV? Please list any questions you would like addressed by Dr. Clymer or the staff: Who can we thank for referring you? Address (if known) Signature
5 Insurance Information As a courtesy to our patients, we will file your charges for insurance eligible services with your insurance company; however, the following information must be filled out completely for your procedures to be filed with your insurance carrier. By signing below I am authorizing Clymer Facial Plastic Surgery P.C., Dr. Mark A. Clymer to furnish all the necessary information to my insurance company, which they may request to process claims, or to comply with any audits that may be requested by my insurance company. I also authorize transmission of my medical records by fax if the necessity should arise. Insurance deductibles, which have not been met, may require payment prior to your surgery. If this form is incomplete, you will be billed directly. Primary Insurance, Information Primary Insurance Address to mail claims Telephone ID# Group # Policy Holder s Name Policy Holder s SSN# Relationship to member Policy Holder s DOB Policy Holder s Employment Self/Spouse/Child/Other Secondary Insurance Information Secondary Insurance Address to mail claims Telephone ID# Group # Policy Holder s Name Policy Holder s DOB Policy Holder s SSN# Relationship to member Self/Spouse/Child/Other Primary Care/Referring Physician Information Primary Care Physician Referring Physician Phone# Phone# Patients Marital Status married separated divorced single (This information is required by your insurance company. Used for insurance billing only). Responsible Party s Signature Guardian If Patient is under 18 Date Date By signing this form, I understand that if my insurance company does not pay the bill submitted by our office in full, I am responsible for any unpaid balance.
6 Clymer Facial Plastic Surgery Permission To release/submit Medical Information Date: I hereby authorize Clymer Facial Plastic Surgery and/or Mark A. Clymer M.D.; to submit or send any records or reports, information or correspondence regarding my care or diagnosis, or to request the release of any information required in conjunction with my care or diagnosis, in order to pre-certify or pre-determine a proposed procedure on my behalf. Patient Witness
1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.
Thomas J. Savage, DPM Jay H. Dworkin, DPM PC 1421 S. Potomac Street, Suite 120 Aurora, CO 80012 303.923.3369 www.metrofoot.org 303.923.3882(fax) Please print and complete all parts. Date PATIENT INFORMATION
Arizona Center for Aesthetic Plastic Surgery Steven H. Turkeltaub, M.D., P.C. Certified, American Board of Plastic Surgery
Referred By: Patient Last Name First M.I. Sex Marital of Birth Age Status Present Mailing Address - Street City State Zip Social Security # Home Telephone # Cell phone # Business Telephone # E-mail address
FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C. PHYSICAL THERAPY INSTITUTE PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Chart #: Today s : FOA Initials: PATIENT INFORMATION Last Name, First Name, MI: Home Phone: Cell Phone: SSN: Birth (MM/DD/YYYY): Age: Sex: Marital Status: Single Separated Male
Ronald E. McFarland M.D. PATIENT REGISTRATION AND HISTORY
Ronald E. McFarland M.D. 2021 Church Street, Suite 606 Nashville, TN 37203 PATIENT REGISTRATION AND HISTORY Date: Primary Care Doctor: Name: Sr. Jr. Address: Street City State Zip Code Telephone: Home
Arizona Center for Aesthetic Plastic Surgery Steven H. Turkeltaub, M.D., P.C. Certified, American Board of Plastic Surgery
Date Referred By: Patient Last Name First M.I. Sex Marital Date of Birth Age Status Present Mailing Address - Street City State Zip Social Security # Home Telephone # Cell phone # Business Telephone #
PATIENT INFORMATION PRIMARY INSURANCE INFORMATION
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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
Patient Information. Patient Name: Preferred Name: Birthdate: SSN: Home Phone: Cell Phone:
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Please Present Insurance Card at Each Office Visit
PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
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 /
PATIENT REGISTRATION
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Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
PATIENT INFORMATION: Patient s D.O.B: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: Home Phone: Cell Phone: Work Phone: Email
PATIENT REGISTRATION
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DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
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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
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DATE Patient: Sabrina A. Lahiri, MD PA Plastic and Reconstructive Surgery 119 Vision Park Shenandoah, TX 77384 Phone: 281-419-1123 Fax: 936-273-8737 Patient Registration Form Patient s Name: (Legal) Last
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LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice.
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Drs. Ellis, Green and Jenkins WELCOME TO OUR PRACTICE Patient Information Today s : First Name: MI: Last Name: _ Birthdate: Age: SS#: _ Marital Status: Married Single Widowed Divorced Separated Address:
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William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español
Active feet are happy feet. William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español New Patient Information Form (Please Print) Date: / / Social
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COLUMBIADOCTORS OPHTHALMOLOGY Edward S. Harkness Eye Institute - 635 W. 165 th Street, New York, NY 10032 880 3 rd Avenue 2 nd Floor, New York, NY 10022 Morgan Stanley Children s Hospital of New York 3959
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