Meritus Digestive Health Specialists
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- Edwin Brooks
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1 Meritus Digestive Health Specialists Medical Campus Road, Suite 246 Hagerstown, MD Phone: Toll Free: Fax: MeritusHealth.com/MMG Dear Patient: It is with pleasure that I welcome you to Meritus Digestive Health Specialists. We will strive to exceed your expectations and provide you with the best service possible. Should you have any questions please do not hesitate to give me a call. To help your first/returning visit with Meritus Digestive Health Specialists go as smoothly as possible please assist us by bringing the following with you: Completed and signed patient registration and history forms. (Attached) Current insurance cards and Picture ID. Insurance referral form, if necessary. Current medications, including vitamins and supplements, with the original bottle or a complete list with strengths and dosage information. A calendar to help with the scheduling of any testing or procedures the doctor may order. Co-payments are collected on the day of your appointment before you see the physician. We accept cash, checks, Visa, MasterCard, Discover, and American Express. If you are unable to make your payment, your appointment will need to be rescheduled. Please review the attached Important Information For Our Patients sheet, once again if you have any questions please do not hesitate to give me a call. Sincerely, Anne Rice, CMPM Office Supervisor Patient s Name: Appointment Date and Time: Physician: Hemant Chatrath, M.D. Nelson L. Ferreira, M.D. Kiran Khosa, M.D. Juan A. Tayler, M.D. MDHS-28 12/16
2 Health History Questionnaire Name: Date: Date of Birth: Current Medical Conditions Reason for current visit: Please describe any special problems that you would lilke to discuss with your doctor today: Current / Past Illnesses: Current Past Approximate Date Current Past Approximate Date Weight loss/gain (past year) Blood Transfusions Headaches/Migraine Anemia/Blood Disorder Valve Dis. Heart Dis. Rheumatic Dis. Varicose Veins/Phlebitis Hypertension Skin Disease Respiratory Disease (TB/Asthma) Diabetes Breast Disease Night Sweats Jaundice/Hepatitis Thyroid Disease Gall Bladder Disease Cancer (Type) H.Hernia/Peptic Ulcer (Type) Bowel Disorders Epilepsy/Neurological Dis. Kidney Disease/Infection Arthritis Urinary Incontinence Psychiatric Urinary Infections Surgical History and Other Hospital Admissions Date Reason for Admission Surgical Procedure: Anesthesia Complications: Yes / No Type: Family History Cancer Diabetes Heart Disease High Blood Pressure Stroke Epilepsy Kidney Disease Emotional / Psychiatric Problems Living Deceased Family History Asthma Breast Disease / Cancer Migraine Headaches Birth Defects Osteoporosis Bleeding/Blood Disorders Endometriosis Living Deceased
3 Social History Diet: Yes / No Type: Exercise: Yes / No Type: Smoking: Yes / No # Cigarettes per day: Alcohol: Yes / No # Drinks per week: Illegal Drugs: Yes / No Domestic Violence: Yes / No Recent / Past Psychological / Sexual / Physical Medications: List ALL current medications Name of Medication Dosage Frequency Name of Medication Dosage Frequency Allergies: For Female Patients Only Please check if you have experienced any of the following in the last 6 weeks: Abnormal Bleeding During Periods Between Periods After Intercourse Abnormal Pap Smear Breast Tenderness/Lumps Burning on Urination Heavy Pressure in Vagina or lower abdomen Comments Loss of Urine when coughing HIV + or sneezing Low Abdominal Pain During Periods Between Periods Uterine Fibroids Hot Flashes/Night Sweats Depression Thyroid Low Back Pain Pain/Difficulty with Intercourse Pelvic Inflammatory Disease PMS Sexually Transmitted Diseases Chlamydia Gonorrhea Syphillis Herpes Genital Warts/HPV Hepatitis Vaginal Discharge/Irritation Endometriosis Infertility Sexual Problems Heavy Menstrual Flow Comments Gynecological History: Age at First Period: First Day of Last Period: Period Interval: #Days Between Periods Duration of Bleeding Cramps: Yes / No Medication for Cramps: Yes / No Number of Periods in Last Year: Date of Last Pap Smear: Results: Normal / Abnormal Date of Last Mammogram: Results: Normal / Abnormal Breast Self Examination: Yes / No Need Instruction? Yes / No Current Method of Contraception (Including vasectomy and tubal ligation) Pill Brand: Problems: Yes / No days Obstetrical History: Past pregnancies including miscarriages or abortions DATE MO/YR GA WEEKS LENGTH OF LABOR BIRTH WEIGHT SEX M/F TYPE DELIVERY ANES. PLACE OF DELIVERY PRETERM LABOR YES/NO COMMENTS/ COMPLICATIONS
4 Meritus Digestive Health Specialists Medical Campus Road, Suite 246 Hagerstown, MD Phone: Toll Free: Fax: MeritusHealth.com/MMG Important Information For Our Patients Meritus Digestive Health Specialists is located in Suite 246 (2 nd floor) of the Robinwood Medical Center. You can use the blue or silver entrance for the nearest parking to the office. Our regular office hours are Monday through Friday 8am. to 4:30pm. Our telephones are on from 8am - 4pm. During your first visit there are no procedures/tests performed. Your procedures or any pre-op tests will be scheduled during this first visit. All directions for the procedures, and questions you may have will be reviewed with you before you leave. A physician is on call 24 hours a day, 7 days a week for your convenience. Please remember the after hours answering service should only be used for emergencies or urgent issues. For prescription refills please call the office at Please allow 2 business days for prescription refill requests to be completed. You may contact your pharmacy if you wish to confirm that your prescription is ready. During your office visits please remind us if you are low on any medication and need refills. This office cannot provide treatment if we do not have your referral. If you do not have your insurance referral form at the time of your visit you will have to reschedule your appointment. This only applies if your insurance requires a referral. Please notify our office if there are any changes to the following information: home address, telephone numbers, insurance information, or primary care physicians. We understand that Maryland has a Social Security Number Privacy Act. We are in compliance, and under this law we DO have the right to use this number for internal verification and/or administrative purposes. We are continually striving to improve our services for our patients. Should you at any time have any questions or concerns during your treatment with our office please contact Anne Rice, our office supervisor at Hemant Chatrath, M.D. Nelson L. Ferreira, M.D. Kiran Khosa, M.D. Juan A. Tayler, M.D.
5 Meritus Digestive Health Specialists Medical Practices of Antietam, LLC Thank you for choosing our practice! We believe that establishing a written financial policy is mutually beneficial for all parties. It is our goal to avoid any miscommunication or concerns regarding financial matters in order to focus our energies on providing healthcare services to our patients. We participate with most insurance plans. Each plan has different benefits for you as well as different financial obligations. Not all insurance policies cover all services. It is your responsibility to check with your insurance company to determine covered benefits, and provide referral at the time of your appointment. The following are our financial guidelines relative to financial responsibility: Payment is expected at the time of service. This includes co-pays, coinsurance, and deductibles. For your convenience we accept cash, check, or credit cards. Please provide a copy of your insurance card at each visit. It is our policy not to extend professional courtesy discounts. For our self pay patients (patients who have no insurance coverage), we offer a 35% discount for professional services paid in full on the date of service. This does not apply to co-pays, co-insurance, deductibles, non-covered services, and medical supplies. For our self pay patients (patients who have no insurance coverage), we offer a 35% discount for hospital services paid in full within 30 days of discharge. This does not apply to co-pays, co-insurance, deductibles, non-covered services, and medical supplies. You may be charged a $25 no-show fee for any appointments missed, not cancelled/rescheduled with a 24 hour notice. Multiple no-shows/cancellations may result in a discharge from practice. Old balances on your account must be paid in full prior to receiving additional services. Accounts may be turned over to a collection agency if past due 60 days or more. A service charge of $30.00 will be added for returned checks, A service charge of $10.00 will be added for co-payments not received on the date of service.. Patients are legally responsible for all collection costs involved with the collection of this account including court cost, reasonable attorney fees, and all other expenses incurred with collection proceedings on any unpaid balance. A parent-or legal guardian must accompany patients who are minors, The accompanying adult is responsible for payment of the account. We appreciate the opportunity to participate in your family s healthcare. If you have any questions regarding this policy, please let us know. I have read, understand, and agree to the above financial policy. I understand that charges not covered by my insurance company, as well as applicable co-pays and deductibles are my responsibility. Printed Name Signature Date
NEW PATIENT REGISTRATION
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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:
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS NAME: LAST FIRST MIDDLE ADDRESS: STREET APT# CITY STATE ZIP HOME # ( ) WORK# ( ) CELL# ( ) E-MAIL: PREFERENCE: HOME: AGE: DATE OF BIRTH: SS NO.: MALE
Whom May We Thank for Referring You? Primary Care Physician. Insured/Responsible Party. Patient Information. Patient s Spouse/Guardian
Whom May We Thank for Referring You? Name: Other: Newspaper Radio TV Seminar Staff Yellow Pages Other Primary Care Physician Name: Address:_ City: State: Zip: Phone: Insured/Responsible Party Patient Information
LOUISIANA UROLOGY, LLC NOTICE OF PRIVACY PRACTICES
LOUISIANA UROLOGY, LLC NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
PLEASE GIVE YOUR INSURANCE CARD(S) AND DRIVER S LICENSE TO THE RECEPTIONIST FOR INSURANCE BILLING PURPOSES
Georgia Spine and Sports Rehab Dr. Joseph A. Krzemien WELCOME TO OUR OFFICE PATIENT INFORMATION FORM NAME DATE OF BIRTH AGE SEX M F ADDRESS CITY STATE ZIP HOME PHONE WORK PHONE CELL SOCIAL SECURITY NUMBER
Island ObGyn Joseph F. Lang, MD
Island ObGyn Joseph F. Lang, MD Patient Name: Billing Address: City: ST: Zip: Other Address: City: ST: Zip: of Birth: Social Security Number: Home Phone #: Work Phone #: Cell Phone #: Email Address: Pharmacy:
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,
Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:
PATIENT INFORMATION Today s : / / Patient Name (Last, Middle, First) Social Security #: Male / Female: of Birth: / / Street Address: Email Address: Home Phone: Mobile Phone: Work Phone: IF THE PATIENT
PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE HOW OFTEN DO YOU
ADVANCED FOOT CARE SPECIALISTS, P.C. 240 W. PASSAIC STREET, SUITE 4 * MAYWOOD, NEW JERSEY 07607 * TEL: 201-880-6000 FAX # 201-880-5999 PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: DATE
HEALTH HISTORY. Physician s Name Phone# Date of Last Visit
HEALTH HISTORY Physician s Name Phone# Date of Last Visit Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combination of Ionamin, Adipex, Fastin (brand
Signature OB/GYN Questionnaire Gynecology Questionnaire SIDE 1 of 2
Questionnaire Gynecology Questionnaire SIDE 1 of 2 Name Date of Birth* Age Race* Ethnicity* Primary Language* Preferred Pharmacy Location Phone#: *Required by Healthcare/Meaningful Use Legislation. FA#:
SRINO BHARAM, M.D., P.C. BOARD CERTIFIED ORTHOPEDIC SURGEON
SRINO BHARAM, M.D., P.C. BOARD CERTIFIED ORTHOPEDIC SURGEON 130 E 77 th Street, 8 Floor www.srinobharammd.com NEW YORK, NY 10075 TEL (212) 691-3535 FAX (212) 691-6370 INITIAL APPOINTMENT INFORMATION Patient
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 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:
PATIENT INFORMATION. Preferred Name: Age: Gender: M F TG. Responsible Guardian(s) Relationship. Billing Address if different: City State Zip
PATIENT INFORMATION Name: Last First MI Address: Street Unit# City State Zip Preferred Name: Date of Birth: _ Age: Gender: M F TG Marital Status: S P M D W Responsible Guardian(s) _ Relationship Billing
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
Dear Patient, Please pay special attention to all policies listed, as you are agreeing to adhere to them.
Dear Patient, Our practice is honored that you have chosen Orange Blossom Women s Group. We strive to perform well above other offices you may have visited in the past, and we hope you will notice the
Welcome to Doctors Foot Center
Dear Patient, Welcome to Doctors Foot Center We are glad you chose Doctors Foot Center for your podiatry needs. Please find the enclosed paperwork required for new patients at our office. Please complete
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION Please complete all attached forms leaving no blanks. Please bring your completed paperwork, insurance card, and picture ID with you to your appointment. ***************************************************************************************************
One Stop Medical Center Tel:
PATIENT DEMOGRAPHICS TODAY S DATE PATIENT NAME BIRTHDATE AGE SEX M F ADDRESS CITY STATE ZIP HOME#( ) CELL#( ) WORK #( ) May OSMC leave a message on your: Home Phone: y n Work: y n Cell : y n MARITAL STATUS
INSURANCE INFORMATION. (Please give your insurance card to the receptionist) / / $ IN CASE OF EMERGENCY
REGISTRATION FORM Today's date: Patient's last name: First:?Addle: Mr. Mrs. Miss Ms. Marital status (circle one) Single I Mar 1 Div / Sep / Wid Is this your legal name? If not, what is your legal name?
GREENWOOD DERMATOLOGY
GREENWOOD DERMATOLOGY Larry J. Buckel, M.D. Thomas J. Eads, M.D. Laura T. Stitle, M.D. Thank you for choosing Greenwood Dermatology for your Dermatologic needs. Dermatologists are the experts in the diagnosis