Gastroenterology - West
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1 Gastroenterology - West Welcome to The Oregon Clinic, Gastroenterology-West! We are pleased that you have chosen us to provide your gastrointestinal care. Please complete the attached forms and bring them with you to your appointment. To facilitate our registration and check-in process, we ask that you please bring your insurance card and photo ID to your upcoming visit. As well, we strongly encourage you to contact your insurance company prior to your upcoming visit to verify your coverage and benefits for your scheduled appointment(s). If your insurance plan requires a copay, it is due at the time of service. If you do not bring your copay to your scheduled appointment, you may be rescheduled. Should you need to cancel or reschedule, please provide 1 business day notice for office visits and 3 business days notice for procedures in order to avoid being charged cancellation/rescheduling fees. Thank you for your time in completing these forms. Should you have any questions regarding your appointment(s), please call Sincerely, The Staff of The Oregon Clinic, Gastroenterology-West CHECKLIST: Detailed list of medications and doses. Insurance card and copay. Photo Identification. Completed Medical History form. Contact insurance company to verify coverage.
2 Gastroenterology - West Medical History Form PLEASE PRINT USING BLACK INK Name Today s Date LAST FIRST MIDDLE Soc. Sec. # Date of Birth Age Sex Primary Care Doctor/Nurse: Referring Provider (if different from PCP): Primary Reason for Today s Visit: Have you ever been treated by another physician for current problems? q No q Yes, name(s) Have you been seen by a GI doctor before? q No q Yes Where? When? Doctor(s) name: Mark all you have experienced in the last six months: q Regurgitation q Heartburn q Difficulty swallowing/food sticking q Nausea q Vomiting q Abdominal pain q Bloating q Diarrhea q Constipation q Blood in stool q Mucus in stool q Change in bowel pattern q Jaundice q Unexplained weight loss Have you ever been diagnosed with one of the following? q Peptic Ulcer q Pancreatitis q Gallstones q Hepatitis Procedures - Have you ever had: Upper GI endoscopy q Yes q No Dates: Sigmoidoscopy q Yes q No Dates: Colonoscopy q Yes q No Dates: q Stomach or q colon x-ray q Yes q No Dates: q CAT scan or q ultrasound q Yes q No Dates: Liver Biopsy q Yes q No Dates: Sedation History Have you previously undergone: q Irritable Bowel Syndrome q Crohn s Disease q Ulcerative Colitis q Diverticulitis q Colon Polyps q Digestive Cancer IV Conscious Sedation (such as for a GI scope procedure )? q No q Yes Were there complications? (Please list) General Anesthesia? q No q Yes Were there complications? (Please list) Continued on next page toc NPP-MH 2/14
3 Name: What Pharmacy do you currently use? Current Medications Please bring a detailed list of medications with doses OR medication bottles OR fill out the table below. (Include over the counter medications and supplements). Medication Dose / Frequency Reason Do you take Coumadin (warfarin) or other blood thinners? q Yes q No Are you taking any supplements that contain Ginkgo Biloba? q Yes q No ALLERGIES to Medications Medication Reaction Do you have an ALLERGY to: Eggs? q Yes q No Soy? q Yes q No Lidocaine? q Yes q No Surgeries: Type of Surgery Date Doctor Where Have you ever been advised to have any surgical operation that has not been done? If yes, please explain: Continued on next page toc NPP-MH 2/14
4 Name: Have you ever been diagnosed with one of the following: q High Blood Pressure q Cancer q Heart Disease q Migraines q Rheumatic Fever q Elevated cholesterol q Stroke q Fibromyalgia q Asthma q Under / over- active thyroid q Arthritis q Diabetes q Gout q Glaucoma q Blood Transfusion Habits: 1) Smoking / Tobacco / Nicotine use: Have you ever smoked or used tobacco / nicotine products? q Yes q No q Currently use: q Cigarettes per day q Chewing tobacco q Nicotine patch For how many years: q Used in the past: q Cigarettes per day q Chewing tobacco q Nicotine patch For how many years: How long ago did you quit? 2) Alcohol use: Do you drink alcohol? q Yes q No q Currently use: How much per week: q beer q wine q liquor q other Was alcohol ever a problem for you in the past? q Yes q No 3) Caffeine use: Do you drink caffeine-containing products? q Yes q No q Current use: How much per day: q coffee q tea q cola q other 4) Do you have a history of recreational or IV drug use? q Yes q No When? Ongoing? q Yes q No Gastrointestinal (Digestive) History of Immediate Family (This section is for family member history, not personal history) Diagnosis Relation Age at diagnosis Digestive Cancer; Type: Type: Crohn s Disease Ulcerative Colitis Irritable Bowel Syndrome Colon Polyps Liver disease Cirrhosis of the liver Gallbladder problems q Ovarian or q Uterine Cancer Other Continued on next page toc NPP-MH 2/14
5 Name: Social History: Marital Status: q Single q Married q Divorced q Widowed q Partnered Children: How many? Ages? How many still living at home? Employment: Where do you work? Job title: How long? Do you have any work-related injury issues? q Yes q No Is there anything else not asked that would be helpful for us to know? PERSONAL HISTORY OF YOUR HEALTH: Please check recent health problems: Constitutional q Fevers q Weight loss q Fatigue q Night sweats Eyes/Ears/Nose/Throat: q Earaches q Hearing loss q Ringing in ears q Blurred vision q Glasses / contacts q Blindness q Sinus pain q Nosebleeds q Dentures q Hoarseness q Mouth sores Skin: q Unexplained rash q Itching Lungs: q Tuberculosis q Chronic cough q Shortness of breath: q exertional q at rest q Wheezing q Sleep apnea Cardiovascular: q Exertional chest pain q Ankle swelling q Irregular heart beat Kidney/Urinary: q Kidney stones q Infections q Burning q Urination at night Musculoskeletal: q Joint swelling q Arthritis q Rheumatoid arthritis q Artificial joints Neurologic: q Blackouts q Dizziness q Difficulty sleeping Psychological: q Depression q Anxiety Hematologic: q Bruising q Excessive bleeding Patient Signature: Date: toc NPP-MH 2/14
6 FINANCIAL POLICY Welcome to our Practice. Please take a moment to review our Payment Policies. We require patients to provide a copy of their insurance card, proof of identification and co-payment at check-in for every visit. If you do not have your insurance card, photo ID or co-payment with you at the time of your visit, your appointment may be rescheduled. PATIENT RESPONSIBILITY Patients are responsible for all charges resulting from treatment provided by The Oregon Clinic. Payment is due in full within 30 days of receiving your first statement unless other financial arrangements have been made with the Business Office. Please remember your insurance policy is an agreement between you and your insurance company, and it is ultimately your responsibility to pay for any balance not paid or covered by your insurance company. REQUIRED PATIENT DEPOSITS-PATIENTS WITH COMMERCIAL INSURANCE COVERAGE Patients will be required to pay a deposit one week prior to their appointment/procedure or their appointment/ procedure will be rescheduled. The deposits are as follows: Procedures $500 (Or their unmet deductible, whichever is less, for non-preventative procedures which may be covered at 100%) REQUIRED PATIENT DEPOSITS-PATIENTS WITHOUT INSURANCE We do offer a 40% discount for patients who do not have insurance. Patients will be required to pay a deposit one week prior to their appointment/procedure or their appointment/procedure will be rescheduled. The deposits are as follows: Office Visit $50 (For new or established patients) Procedures $500 CO-PAYMENTS, DEDUCTIBLES AND CO-INSURANCE Co-payments are the amounts your insurance policy requires us to collect with each visit, and are due at the time of service. Patients who arrive without their co-pay may be rescheduled. The deductible is the total amount your policy requires you to pay before they will pay claims on your behalf. We may ask you to pay the estimated, unmet portion of your deductible before services are rendered. The co-insurance is the percentage of the bill that is your financial responsibility according to the contract with your insurance company. We accept cash, check, VISA, MasterCard and American Express. You are welcome to pay through our online payment system on our webpage; PAYMENT ARRANGEMENTS All patients will be required to pay off their balances within 30 days of receiving their first statement unless payment arrangements have been made with the Business Office. Please contact our Business Office at as soon as possible after receiving your statement if payment arrangements are needed.
7 FINANCIAL POLICY Page 2 REFERRALS AND PRE-AUTHORIZATIONS The Business Office will attempt to obtain a referral from your Primary Care Physician if your insurance company requires one. Please be aware that if you choose to be seen before you have received a valid authorization, your insurance company may not pay for the visit. The Business Office cannot guarantee payment for services or coverage of services from your insurance company. If a referral has not been received hours prior to your appointment, your appointment may be rescheduled. INSURANCE BILLING As a courtesy, we will bill your primary and secondary insurances for you. However, primary responsibility for the account is yours. Providing correct insurance billing information is the responsibility of the patient. If your insurance changes, please present your new card at your visit. All of our providers are participating with Medicare. If you are insured directly through the State of Oregon or are insured through the Oregon Health Plan, please bring your current medical card with you to your appointment. If you do not have your insurance card with you at the time of your visit to provide us with valid insurance information, you will be billed for the services, or your appointment rescheduled. CANCELLATION AND RESCHEDULING FEES If you need to cancel or reschedule your procedure, you must notify us within 3 business days of your procedure time. You may be charged a $100 cancellation/reschedule fee for insufficient notice for procedures. If you need to cancel or reschedule your office visit, you must notify us within 1 business day of your office visit time. You may be charged a $50 cancellation/reschedule fee for insufficient notice for office visits. NO-SHOW FEES You may be charged $100 for not showing for your scheduled procedure. You may be charged $50 for not showing for your scheduled office visit. If you have a pattern of no shows and/or late cancellations, you may be terminated from the practice. INTERPRETER FEES If we have arranged for an interpreter for your visit or procedure, the interpreter service requires a 24 hour notice of cancellation. If you do not show or cancel late, you may be billed for the interpreter fee, in addition to the fees above. PAST DUE AND COLLECTION ACCOUNTS We reserve the right to send accounts with balances that have been outstanding over 90 days from the date of service or the date of payment received from your insurance company, whichever is more, to a collection agency. If you have a balance on your account that is more than 90 days old, and over $300, you will be referred to the Financial Counseling Department to make payment arrangements. If any portion of your past due amount has been assigned to a collection agency, we will request that you pay one-half (½) of that collection balance before your appointment is scheduled with our office. The patient s signature (or the signature of the patient s parent or legal guardian) acknowledges that you understand and accept the above information. I have read the above Financial Policy and agree with the terms of this agreement. Print Name Date Signature
8 NOTICE OF REFERRAL RIGHTS AND ACKNOWLEDGMENT THIS NOTICE DESCRIBES YOUR REFERRAL RIGHTS WHEN YOUR HEALTH CARE PROVIDER REFERS YOU TO ANOTHER PROVIDER OR FACILITY FOR ADDITIONAL TESTING OR HEALTH CARE SERVICES. In accordance with Oregon law, when you are referred for care outside of our clinic, we, The Oregon Clinic-GI West, are required to notify you that you may have the test or service done at a facility other than the one recommended by your physician or health care provider. Oregon law says (ORS ): A referral for a diagnostic test or health care treatment or service shall be based on the patient s clinical needs and personal health choices. A health practitioner or the practitioner s designee shall provide notice of patient choice at the time the patient establishes care with the practitioner and at the time the referral is communicated to the patient. The oral or written notice of patient choice shall clearly inform the patient: (a) That when referred, a patient has a choice about where to receive services; and (b) Where the patient can access more information about patient choice. The patient has a choice and when referred to a facility for a diagnostic test or health care treatment or service the patient may receive the diagnostic test or health care treatment or service at a facility other than the one recommended by the health practitioner; If the patient chooses to have the diagnostic test, health care treatment or service at a facility different from the one recommended by a practitioner, the patient is responsible for determining the extent of coverage or the limitation on coverage for the diagnostic test, health care treatment or service at the facility chosen by the patient. A health practitioner shall not deny, limit or withdraw a referral solely because the patient chooses to have the diagnostic test or health care treatment or service at a facility other than the one recommended by the health practitioner. July 2014 Notice of Referral Rights Oregon Medical Association
9 Directions to: The Oregon Clinic, Gastroenterology-West Gastroenterology - West 9701 SW BARNES ROAD, SUITE 300 PORTLAND, OREGON FAX The Oregon Clinic, Gastroenterology-West Peterkort Centre 9701 SW Barnes Road, Suite 300 Portland, Oregon From Downtown Portland on Burnside Road West: Continue straight through the Miller Road intersection on Barnes Road. St. Vincent Hospital will be approximately two miles down on the right side of Barnes Road. Just past the hospital take an immediate right onto Baltic Avenue. Veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Downtown Portland on Highway 26 West: Continue on Highway 26 for six miles to the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From the Oregon Coast: Take Highway 26 East to the Park Way/Barnes Road exit, #69B. At the 1st light, follow the right fork (Blue signs will direct you to the Hospital). Continue straight through the next two signals (you will cross Barnes Road and you must be in the center lane to do so) and veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Washington: Take I-5 South to the 405 southbound exit across the Fremont Bridge. From there, take the Beaverton/Highway 26 West exit. Continue on Highway 26 for six miles and take the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Southern Oregon: Take I-5 North and exit onto Highway 217 North. Stay on Highway 217 for six miles (until it ends). Follow the Barnes Road East sign which will put you onto Barnes Road eastbound. Go to the first light and take a left onto Baltic Avenue. Veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Eastern Oregon: Take I-84 West to I-5 South and stay in the left lanes heading toward Beaverton. Cross the Marquam Bridge and take exit 1-D to Highway 26 West. Continue on Highway 26 for six miles and take the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. toc NPP-MAP 2/14
Gastroenterology West
Gastroenterology West Welcome to The Oregon Clinic, Gastroenterology West! We are pleased that you have chosen us to provide your gastrointestinal care. Please complete the attached forms and bring with
PATIENT REGISTRATION
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First Name: MI: Last Name: Address: City: ST: Zip: County: Referring Physician: Home Phn: Work Phn: Cell Phn:
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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:
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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
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
Here is a quick review of all the things you will need to make your first visit go smoothly. We hope you find this helpful.
Smith Tower 6550 Fannin St., Suite 2237 Houston, TX 77030 Ph: 713-790-4600 Fax: 713-793-1229 Appointment Date: Time: Doctor: Dear New Patient: Welcome to our practice and thank you for giving us the opportunity
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
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
**The Dermatology Clinic sends all appointment reminders via text**
PATIENT INITIAL EVALUATION INFORMATION (Adult) DATE Patient Name Date of Birth / / First Middle Last Month Day Year Mailing Address Street City State Zip Home Phone Work Phone Cell Phone **The Dermatology
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:
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
Welcome! Your Appointment Details: Day: Date: Time: am / pm. Please arrive 15 minutes prior to your appointment time.
Welcome! Dear New Patient, Thank you for choosing Southern Oregon Foot & Ankle for your podiatric care! Please fill out the enclosed forms and bring them with you to your appointment. Your Appointment
PATIENT INFORMATION FULL NAME First M.I. Last CONTACT INFORMATION
PATIENT INFORMATION FULL NAME First M.I. Last DATE OF BIRTH SOCIAL SECURITY # M / D / Y AGE: SEX: MALE or FEMALE STREET APT/SUITE #: CITY, STATE, ZIP City State Zip INSURANCE NAME POLICY/MEMBER ID: HOME
LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice.
LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only
Do you have or have you ever had any of the following: Circle Yes (Y) or No (N)
PATIENT MEDICAL HISTORY FORM West Georgia Urology Associates, P.C. 150 Clinic Avenue, Suite 202 Carrollton, GA 301117 Phone:( 770) 834-6988 Fax: (770) 834-1090 Today s Date: Name: _ (Last) (First) (Middle
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
Riverview Orthopedics and Sports Medicine 493 Westfield Rd
Dear New Patient, Riverview Orthopedics and Sports Medicine 493 Westfield Rd Noblesville, IN 46060 (317)-770-4100 (Fax: 317-770-4105) Tipton: 765-675-0030 Thank you for choosing our practice for your orthopedic
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#:
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
ATLANTA PLASTIC & RECONSTRUCTIVE SPECIALISTS, LLC PEACHTREE DUNWOODY RD SUITE 870 ATLANTA, GA fax
ATLANTA PLASTIC & RECONSTRUCTIVE SPECIALISTS, LLC. 5673 PEACHTREE DUNWOODY RD SUITE 870 ATLANTA, GA 30342 404-255-2975 404-255-2276 fax Today s Date Last Name First Name Middle Name Patient s Social Security
Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:
PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally
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
WESTCHASE GASTROENTEROLOGY
Today s : WESTCHASE GASTROENTEROLOGY John Chang, MD, FACG Amir Awad, MD, FACG Alfredo Mendoza, MD, MS 11912 Sheldon Road, Tampa FL 33626 4695 Van Dyke Road, Lutz FL 33558 Telephone: 813.920.8882 Fax: 813.920.8883
SAGUARO SURGICAL PATIENT REGISTRATION FORM
Account # Date Patient Name: M F Last First Legal Nickname MI Is this your legal name? Yes No If no, what is your legal name? Marital Status: SAGUARO SURGICAL PATIENT REGISTRATION FORM Single Married Divorce
LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# ADDRESS:
PATIENT INFORMATION LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# EMAIL ADDRESS: OCCUPATION: EMPLOYER: RACE: ETHNICITY: White
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:
Colorado Clinics for the Foot and Ankle Dr. Erik Ouderkirk, DPM Dr. Corey Bess, DPM
Date: Colorado Clinics for the Foot and Ankle Dr. Erik Ouderkirk, DPM Dr. Corey Bess, DPM 2373 Central Park Blvd. Ste. 201 Denver CO 80238 11310 N Huron St. Ste. 20 Northglenn CO 80234 4185 East Wildcat
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
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
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
PATIENT INFORMATION. Patient s Last Name First M.I. Home Phone Work Phone Cell Phone Home Address City State Zip Address
PATIENT INFORMATION Patient s Last Name First M.I. Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Address Social Security # Sex Marital Status Patient s Date of Birth Age Spouse s
Patient Registration Form
Patient Registration Form Name: Last First MI Today s Date: Address: Street City State Zip Phone: Best # Daytime # Cell # Date of Birth: Male Female Occupation: Employer: Social Security #: Email: Spouse
Gastroenterology Specialists, Inc.
Email Address: John R. Hood, M.D. Michael J. Martin, M.D. William K. Briggs, M.D. Jeffrey L. Bigler, M.D. 10210 East 91st Street South Tulsa, Ok 74133 (918) 940-8500 Gastroenterology Specialists, Inc.
Previous Podiatric History Previous Surgical History Height Weight Shoe Size Are You Allergic to Any of the Following?
Associated Podiatrists, P.C. 26750 Providence Parkway Suite 130 - Novi, MI 48374 Telephone: (248)348-5300 PLEASE FILL OUT COMPLETELY Today s date Name (First, Middle, Last): DOB: Home Address: City State
GASTROENTEROLOGY PRACTICE ASSOCIATES PATIENT REGISTRATION
GASTROENTEROLOGY PRACTICE ASSOCIATES PATIENT REGISTRATION Please Print Clearly Patient s Name: SS #: First Name Middle Name Last Name Date of Birth: Male Female Single Married Widowed Divorced Separated
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
Patient Last Name: First MI. Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone:
Patient Last Name: First MI Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security No.: Sex: Marital Status:
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
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 History Form for Dr. Robert Burger
Patient History Form for Dr. Robert Burger Patient Name (print): Date of Birth: Gender: Male Female Marital Status: Single Married Divorced Widowed Ethnicity: Race: Preferred Language: Referred to Dr.
Welcome To Our Office Please Print
1 PATIENT INFORMATION Date Home Phone ( ) E-mail Street City State Zip Marital Status Children? Ages Occupation May we call you at work? Y N Work Hours SPOUSE/DOMESTIC PARTNER INFORMATION (If appropriate)
Family Medicine Center of the Bitterroot, P.C.
PATIENT REGISTRATION / FINANCIAL AGREEMENT Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges
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:
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
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Name: Primary Phone: Secondary Phone Address:_ City: State: Zip: Social: Age: DOB: Height: Weight: Primary Physician: _ Referral Source: Email Address: HISTORY Chief Complaint:
The comfort of home, the care of professionals
Gary K. Fowers, MD Barry A. Noorda, MD David A. Kirkman, MD Anne S. Blackett, DO The comfort of home, the care of professionals #P2 Amy Billings, PAC Anna Lara, PAC D Anne Moon, CNM Kenneth A. Wade, PAC
central oregon EAR NOSE THROAT
Medications: (list all your current medications and the dose) Allergies: (List medications/foods and what happens) Allergies to tape, iodine or latex: List the dates for the following radiology tests:
Babak N. Rad, M.D., Inc.
, Inc. PERSONAL INFORMATION Date Last Name First Name M.I. Date of Birth Age Marital Status S M D W Social Security Number Home Address City State Zip Home Phone Cell Phone Work Phone Preferred Method
2345 Court Drive Gastonia, NC Phone: Fax:
Patient Name: Address: Street City State Zip SSN: Home #: Birth Age: Sex: Male Female Email Address: Marital Status: Single Married Divorced For X-ray purposes, are you pregnant? Yes No Patient s Employer: