WELCOME TO OUR PRACTICE! We look forward to seeing you very soon.
|
|
|
- Gervais Melton
- 6 years ago
- Views:
Transcription
1 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, financial policies, and procedures. We ask that you fill out the enclosed paperwork and bring it with you to your first appointment. Please make sure your medical history is accurate and complete. Include all information regarding the medications and vitamins you take, along with the dosage and frequency. Bring along your current insurance card and drivers license. Payment is expected at the time of service for all co-payments and non-contracted or cosmetic services and fees. We are committed to exceeding each of our patients needs and encourage you to let us know what we can do to best help you. Please keep your scheduled appointment, or provide us with at least 24 hours notice in the event that you need to cancel or reschedule to avoid paying the$50.00 cancellation fee. You may visit our web site for more information and for directions to our office. We look forward to seeing you very soon.
2 PATIENT DEMOGRAPHICS Date Mrs Ms Mr Dr Legal Name: Nickname: Mailing Address _ City: State: Zip Code: Date of Birth: SSN: Marital Status: Spouse s Name: Primary Phone: Home Work Cell Secondary Phone: Home Work Cell address: Exclude From Marketing Occupation: Place of Employment: EMERGENCY CONTACT Person to Notify: Relationship If Patient is a child: Other Parent: Phone: Phone: REFERRAL INFORMATION How Were You Referred to Our Office? Referring Dr Address: Phone Referring Patient: Reason for Appointment Functional Cosmetic PRIMARY CARE PROVIDER Provider Name: Phone: Address: Other Specialist(s) You See (Cardiologist, Endocrinologist, Oncologist, Plastic Surgeon, Etc.): Name Specialty Phone Name Specialty Phone Name Specialty Phone PREFERRED PHARMACY Name Cross Streets Phone INSURANCE GUARANTOR Primary Insurance Subscriber DOB: Secondary Insurance: Subscriber DOB: Subscriber Name: Relationship: Subscriber Name: Relationship
3 CONFIDENTIAL MEDICAL HISTORY FORM PATIENT NAME: DATE: 1. Please list all medications you take on a regular basis: (Include eye drops, vitamins, herbs, & over the counter products such as aspirin or aspirin containing products.) Medication Strength/Dose Frequency Please list all illnesses/diseases which you have had or have now: Please list all prior surgeries or procedures: Surgery Physician Approximate Date Please list any allergy or sensitivity to medication or food: None MedicationReaction Height Weight
4 PATIENT NAME: 5. HAS ANYONE IN YOUR FAMILY HAD THE SAME PROBLEM THAT BRINGS YOU TO OUR OFFICE? [ ] Yes [ ] No If yes, who? DO ANY OF THESE DISEASES RUN IN YOUR FAMILY? IF YES, PLEASE NOTE RELATIONSHIP Glaucoma Do you smoke? If YES, how much? Diabetes High blood pressure Skin cancer Drink alcohol? If YES, how much? Other 6. DO ANY OF THE FOLLOWING PROBLEMS APPLY TO YOU? IF YES, PLEASE EXPLAIN. Constitutional (fever, weight loss, poor appetite, etc.) Eyes (Glaucoma, cataract, lazy eye, retina problems, etc.) Ear/Nose/Throat (hearing loss, sinus problems, sore throat, frequent bloody noses, etc) Cardiovascular (heart problems, chest pain, high blood pressure, stroke, pacemaker, heart surgery) Respiratory (asthma, shortness of breath, wheezing, coughing, etc) Gastrointestinal (heartburn, diarrhea, vomiting, abdominal pain, etc.) Genitourinary (urinary problems, blood in urine, etc) Skin (skin rashes, excessive dryness, used Accutane, skin cancer/diseases, etc.) Musculoskeletal (muscle aches, joint pain, swollen joints, artificial joint, arthritis, etc.) Neurological (numbness, weakness, paralysis, headaches, spasm, MS, etc.) Hematologic (blood disorders, leukemia, easy bleeding/bruising, take aspirin, etc.) Allergy (hay fever, seasonal allergies, etc.) Endocrine (thyroid or pituitary problems, etc.) Psychiatric (depression, anxiety, etc.) Hepatitis B or C, HIV or AIDS, Tuberculosis, etc. Diabetes, radiation treatments, anesthesia reactions, etc. Other Comments: Physician Initials Date:
5 CANCELLATION/NO SHOW/FINANCIAL POLICY 1. Cancellation/ No Show Policy for Office Appointments We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly full appointment book. If my office appointment is cancelled within 24 hours of the scheduled time, I agree to pay a $50.00 fee. I understand this fee will not be covered by my insurance. 2. Cancellation/ No Show Policy for Surgery Due to the large block of time and professional staff needed for surgery, last minute cancellations can be problematic for surgery coordination and add expenses for the surgeon. If my surgery is cancelled within 10 business days of the scheduled date, I agree to pay a $ administrative fee. I understand this is fee will not be covered by my insurance. 3. Financial Policy Account balances We require that cosmetic/self-pay treatments be paid in full prior to services rendered. Account balances assessed to patient responsibility by third party payers must be paid in full or arrange a payment plan prior to receiving further services from our practice. Patients who have questions about their bills or who would like to discuss options for payment plans may call and ask to speak to our Patient Financial Coordinator with whom they can review their account and concerns. Checks returned for non-sufficient funds or other reasons will result in an additional charge of $35 for re-processing. In case of default payment, I agree to pay any and all costs of collecting this account including but not limited to a collection fee of 40%, attorney fees and court costs. PATIENT NAME SIGNATURE DATE
6 HIPPA POLICY & NOTICE At Park Avenue Oculoplastic Surgeons (PAOS), we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, how and when we use and disclose of that information. It also describes your rights as they relate to your protected health information. This Notice is effective March 1, 2003 and applies to all protected health information as defined by federal regulations. Understanding Your Health Record Information Each time you visit PAOS, a record of your visit is made. Typically this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment Means of communication amongst the many health professionals who contribute to your care Legal document describing the care you received Means by which you or a third party payer can verify that services billed were actually provided A tool in educating health professionals A source of data for medical research A source of information for public health officials charged with improving the health of this state and nation A source of data for our planning and marketing A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, where and why others may access your health information, and make more informed decisions when authorizing disclosures to others. Your Health Information Rights Although your health record is the physical property of PAOS, the information belongs to you. You have the right to: Obtain a paper copy of this notice of information practices upon request Receive a copy your health record as provided for in 45 CFR Amend your health record as provided for in 45 CFR Obtain an accounting of disclosures of your health information as provided in 45 CFR Request communications for your health information by alternative means or at alternative locations Revoke your authorization to use or disclose health information except to the extent that action has already been taken. Our Responsibilities PAOS is required to: Maintain the privacy of your health information Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you Abide by the terms of this notice PATIENTSIGNATURE(OR AUTHORIZED REPRESENTATIVE) DATE NAME
7 INSURANCE BILLING AGREEMENT BY SIGNING BELOW I AGREE TO THE FOLLOWING: I authorize Park Avenue OculoPlastic Surgeons, PC (PAOS) and/or Park Avenue Surgery Center, LLC (PASC) to give me reasonable and proper medical care by today s standard. I understand that all charges are payable on the day service is rendered if not covered by insurance. I understand it is my responsibility to verify with my insurance carrier that my provider at PAOS is participant of my insurance plan. I authorize PAOS/PASC to bill my insurance company. Regardless of insurance coverage, I am responsible for all bills being paid in a timely manner. I understand that my contract is between PAOS/PASC and myself. I authorize PAOS/PASC to release any medical or other necessary information that my insurance carrier may require concerning my personal health information in either paper or digital from. I agree to assign all payments for all services rendered to PAOS/PASC. PATIENT SIGNATURE DATE PRINTED NAME
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
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
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 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#:
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:
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
Arizona Retina Institute Patient Registration Form Patientʼs Name:" " " " " " " Todayʼs Date:" /" / Patientʼs Social Security#" " " " " Date of Birth:" /" / Gender: Male " Female Marital Status: Single
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
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
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,
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: --------------------------------------
Arthur M. Cotliar, M.D. & Staff
Dear Patient: Thank you for taking time to schedule an appointment at one of our offices. Please fill out the enclosed forms and bring the forms with you on the day of your appointment. In addition, please
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
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
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
EMERGENCY CONTACT INFORMATION PATIENT EMPLOYER INFORMATION GUARANTOR / POLICY HOLDER INFORMATION INSURANCE INFORMATION
Physician Name: David R. Lionberger, M.D. PATIENT DEMOGRAPHIC INFORMATION SHEET Last Name First Name Middle Social Security No. Date of Birth Age Male or Female (Please circle one) Marital Status: M S
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
Jandali Plastic Surgery
Jandali Plastic Surgery PATIENT INFORMATION FORM : FirstMiddle Last Address: City State Zip Code Home Phone #( ) - Work #( ) - Cell #( ) - Emergency # ( ) - Emergency Contact Social Security Number - -
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?
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:
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
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):
Greenbriar Vision Center Welcomes You Please Print Clearly
Greenbriar Vision Center Welcomes You Please Print Clearly First Name Last Name Today s Date Address City State Zip Code Home # Work # Cell # Email Sex: Birth date: Age: Parent/Guardian s name (if patient
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:
Welcome to Kapolei Eye Care
Welcome to Kapolei Eye Care NN Paper Acct#: PLEASE COMPLETE ALL PORTIONS OF THE THIS FORM (FRONT AND BACK) AS BEST AS YOU CAN PATIENT INFORMATION (Please provide your picture ID to the receptionist to
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
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
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
BRAMLETT ORTHOPEDICS
BRAMLETT ORTHOPEDICS 200 Montgomery Highway, STE 200 Birmingham, AL 35216 Patient Information Phone: 205-783-5900 Fax: 205-783-5906 Patient Information Name (Last, First, Middle) Social Security Number
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)
Personal Medical History Form Please Print
Personal Medical History Form Please Print PATIENT S LEGAL NAME: REFERRED BY: REASON FOR VISIT: TODAY S DATE: BIRTH DATE: PLEASE ANSWER ALL OF THE QUESTIONS AS ACCURATELY AS POSSIBLE. IF YOU DO NOT UNDERSTAND
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
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:
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:
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 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
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):
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
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]:
COSMETIC HISTORY FORM
COSMETIC HISTORY FORM IF THIS IS YOUR FIRST VISIT WITH US, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone:
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):
PATIENT S INFORMATION
David O. Magnante, M.D. 975 Mezzanine Drive, Suite B Lafayette, IN 47905 PH: 765449.7564 FX: 765.807.7943 PATIENT S INFORMATION Patient s Social Security# - - Date Name Last First Middle Initial Home Address
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
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
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:
Address: How did you hear about us? Name: Date of Birth: / / Address: City: State: Zip code: Phone Number: HOME - - WORK - - CELL - - EMPLOYER:
Date of Appointment: / / Email Address: How did you hear about us? Have you been seen here before? YES NO If YES, WHEN?: PATIENT INFORMATION Name: Date of Birth: / / AGE: SSN: - - GENDER: Male Female Marital
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
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 # (
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
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:
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:
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
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
Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA Phone: Fax:
Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA 98902 Phone: 453-2010 Fax: 225-6421 Patient Name: Last: First: Middle Initial: Nickname: Sex: M / F Date of Birth:
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:
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
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:
Your appointment at Dry Eye Institutes of America is scheduled on, at am/pm at our Grapevine location.
Dear New Patient, Thank you for choosing Dry Eye Institutes of America. We strongly believe in a TEAM approach to patient care and our team is committed to providing a smooth patient experience. Our holistic
Worthington Family Dentistry, P.C Greystone Way Valdosta, GA (229)
Worthington Family Dentistry, P.C. 3362 Greystone Way Valdosta, GA 31605 (229) 242-0063 Patient Information Date Name Home Phone Cell Phone (Last) (First) (Initial) Work Phone Other/Fax Sr., Jr., III,
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 #
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
Winter Park Colon & Rectal Specialists, LLC JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 Winter Park, FL 32792
JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 DATE: PLEASE PRINT NAME: Last First MI GENDER: M F DATE OF BIRTH: AGE: SSN: _ MARITAL STATUS: Single Married Widowed Divorced Separated RACE: White Black
TEXT YES VOICE YES PHONE NUMBER PHONE NUMBER
Dr. Gann's Diet of Hope Name: D.O.B To allow patients to easily access their statements and communicate with Providers we are glad to provide you access to our Patient Portal. Please provide your 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 /
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
Patient Information. Who is your primary care physician? Phone:
Patient Information Date: Patient Name: Name you go by: Street Address: Mailing Address (if different): City, State, Zip code: Date of Birth: Sex: M / F Marital Status: Single / Married / Divorced / Widowed
MarinEyes 901 E Street San Rafael CA 9490 Tel: CITY STATE ZIP CODE HOME PHONE CITY STATE ZIP CODE
MarinEyes 901 E Street San Rafael CA 9490 Tel: 415-454 5565 MarinEyes 165 Rowland Way, Suite 207 Novato, CA 94945 Tel: 415-892-0111 PATIENT INFORMATION NAME (Last) (First) (Middle) BIRTHDATE SSN# SEX EMAIL
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 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
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
Patient Demographic Information
Patient Demographic Information Write your name as it appears on your insurance card. Please complete this form in its entirety Name: Male Female Date of Birth: Primary Insurance: Secondary Insurance:
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
ANN BULLINGTON, M.D. ROBERT H. BULLINGTON, JR., M.D. Cornea and External Diseases AILEEN F. VILLAREAL, M.D. ROBERT E. FINTELMANN, M.D., F.A.C.S. Cornea, Cataract, and Refractive Surgery Welcome to Biltmore
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
Welcome to Biltmore Eye Physicians! Enclosed in our new patient packet are the following items: 1. Patient Registration 2. Credit Policy and Financial Agreement 3. Notice of Privacy Practices 4. Medical
***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
Patient Health History Form
Patient Health History Form PATIENT INFORMATION Patients Legal Name: Name that child likes to be called (Nickname): DOB: Current Age: SOURCES OF INFORMATION Name of Person Providing Information: Relationship
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#:
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
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA (540) PHONE (540) FAX
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first
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
PATIENT REGISTRATION FORM
ph. 912.303.0891 x: 912.303.0893 UROGYNsavannah.com 5356 Reynolds Street Suite 301 Savannah, GA 31405 PATIENT REGISTRATION FORM Date Patient Name DOB SSN (Last, First, Middle Initial) Address: (City, Street,
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA (619)
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA 91942 (619) 463-4486 PATIENT INFORMATION Last Name First Name Middle Initial *If Patient is a child, Parent/guardian
Natural Image Skin Center Registration Form
Natural Image Skin Center Registration Form New Patient Name Change Address Change Insurance Change Please present ALL Insurance cards to the receptionist. If patient is a minor, and you are not the legal
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
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
Please complete entire form
Please complete entire form Patient Name: (Last) (First) (M) Address: City: State: Zip: DOB: Age: Sex: M F Social Security #: (If Using Insurance this is required) Home Phone: Cell Phone: Work Phone: Marital
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
MEDICAL FORM (Please Fill in all Information)
MEDICAL FORM (Please Fill in all Information) Last Name First M.I. Spouse/Parent Name Home Phone Business or Cell Phone Home Address City and State Date of Birth Zip Code Sex M F Social Security # E-Mail
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
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,
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:
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 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
Drs. Lawaczeck, McKinnon, Feagin, Carter, & Gee, P.C PATIENT REGISTRATION
Drs. Lawaczeck, McKinnon, Feagin, Carter, & Gee, P.C PATIENT REGISTRATION Patient Name. Today s Date FIRST MIDDLE LAST Home Address City State Zip Code Daytime PhoneSecondary/ Cell Phone Date of Birth
What to bring to the appointment
What to bring to the appointment Welcome to our practice. We appreciate you choosing us for your urologic care. Enclosed are forms that should be reviewed and filled out before your appointment. They include:
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:
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 / 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 NAME: SEX: M / F DATE OF BIRTH: AGE: S.S# ADDRESS: Street: City: State: Zip Code:
Plastic Surgery Specialists, P.C. Dennis T. Monteiro, M.D., F.A.C.S. Emely J. Karandy, D.O., F.A.C.O.S. John T. Louis, M.D., F.A.C.S. William C. Dilks, C.R.N.P. Diana B. Bragoli, C.R.N.P PATIENT NAME:
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: