CENTERS FOR HEALTHY LIVING
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1 PATIENT REGISTRATION FORM Date Name Address Zip City St. Date of Birth Social Security# Home# Cell# Work # Occupation Health Insurance Policy# Group # How did you hear about us? I authorize Centers For Healthy Living to treat me as necessary. I authorize any information necessary to be released to my insurance carrier for this or a related claim. I accept responsibility for all copayments and deductibles due at the time of service. I agree to be responsible for any balance not covered by my insurance carrier or responsible party. ( ) I have received a copy of Notice of Provider Privacy Practices handout. ( ) I have received a copy of Your Health Information Rights handout. PATIENT SIGNATURE THIS SECTION FOR STUDENTS ONLY Name of parent responsible for your medical bills Address
2 All contact numbers PERSONAL MEDICAL HISTORY Name Primary Doctor Date of last visit Allergies All medications you are taking Current medical problem Chronic medical conditions Previous Surgeries When was your last Period Mammogram Pap Smear Dexa scan Colonoscopy Prostate Exam Please check any of the following that apply to you: High blood pressure Depression High cholesterol Migraines/Frequent headaches Cardiovascular Disease Cancer type of Diabetes Eating Disorders Osteoporosis Stroke Benign Prostatic Hyperplasia Phlebitis/Clots/Varicose veins Seizures Vision Problems Tobacco use Liver Disease/Hepatitis Alcohol use Mononucleosis Caffeine use Kidney/Bladder problems Asthma/COPD/TB Thyroid Disease Erectile Dysfunction Anemia/Sickle cell Insomnia Abnormal mammogram Muscle loss Breast lumps/discharge Decreased Libido Other FAMILY HISTORY Are you adopted? Indicate who of your blood relatives (parents, grandparents, siblings) have or had any of the following problems: Heart attack/coronary artery disease High blood pressure Diabetes Stroke Cancer typeof Phlebitis/clots in veins Birth defects/genetic disorders Sickle cell Tay Sachs Thalassemia PATIENT SIGNATURE DATE
3 NOTICES OF PROVIDER PRIVACY PRACTICES Centers For Healthy Living must maintain the privacy of you personal health information and give you this notice that describes the legal duties and privacy practices concerning you personal health information. Without your written authorization, we can use your health information for the following purposes: 1. Treatment: The treatment selected will be documented in your medical record so that other health care professionals can make informed decisions about your care. 2. Payment: In order for an insurance company to pay for your treatment, we must submit a bill that identifies you, your diagnosis, and the treatment provided to you. In the cases in which this is done electronically, the company we deal with is in compliance with all regulations regarding privacy. 3. Health Care Operations: Your insurance company may require regular inspection information of our charts to monitor patient care. Appointment reminders will be a phone call to the patient directly. No messages will be left without the express consent of the patient. Mailed notices for appointments or treatment will be sealed card. 4. As required or permitted by law: Sometimes we must report some of your health information to legal authorities. 5. For public health activities: We may be required to report your health information to authorities to help prevent or control disease, injury or disability. 6. For activities related to death: We may disclose your health information to medical examiners and funeral directors so they can carry out their duties related to the death of you or your infant 7. For organ, eye or tissue donation: We may disclose your health information to people involved with obtaining, storing or transplanting organs, eyes, or tissue of cadavers for donation purposes. 8. For military, national security, or incarceration/law enforcement custody: If you are in the custody of law enforcement officials, we may release your health information to the proper authorities so they may carry out their duties under the law. 9. For worker s compensation: We may disclose your health information to the appropriate persons in order to comply with the laws related to worker s compensation or other similar programs. NOTE: Except for the situations listed, we must obtain your specific written authorization for any other release of your health information. If you sign an authorization form, you may withdraw you authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw your authorization, please submit your written withdrawal to the privacy officer.
4 YOUR HEALTH INFORMATION RIGHTS The health and billing records we maintain are the physical property of the doctors office. The information in it, however, belongs to the patient. The patient has a right to: Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any reasonable request. Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a request at our office. Request that you be allowed to inspect and copy your health record and billing record-you may exercise this right by delivering the request in writing to our office using the form we provide to you upon request. Appeal a denial of access to your protected health information except in certain circumstances. Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request. The physician is not required to make such amendments. File a statement of disagreement if your amendment is denied and required that the request for amendment and any denial be attached in all future disclosures of your protected health information. Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide you upon request. Revoke authorization that you made previously to use or disclose information except to the extent that information or action has already been taken by delivering a written revocation to our office. All patients regardless of age have a right to privacy with their health care information in regards to the pregnancy and birth control. If you want to exercise any of the above rights, please contact the privacy officer at this office. This notice of privacy rights is in effect as of April 14, 2003
5 RELEASE OF CONFIDENTIAL MEDICAL INFORMATION Centers For Healthy Living and staff consider all patient information confidential. List all individuals with who we may discuss your medical condition, test results, and/or treatment plan. Please sign below indicating you have given this authorization. You may discuss my treatment with: 1) Name: Relationship: 2) Name: Relationship: Patient Signature: Print Name:
6 FINANCIAL POLICY We will gladly submit your insurance provided you agree to pay the portion you are responsible for. Your responsibility includes any deductible or co-pay that applies to the visit or the entire amount of the claim should your insurance completely deny. An estimate of your responsibility will be collected at the time of the visit. After insurance pays or denies a claim we will send you a statement. Your amount due is expected by the due date on the statement. If your amount due is too large to pay by the due date please call to discuss payment arrangements. Statements that are ignored will be sent to collections. All accounts turned over to collections will be charged a 50% fee. Some procedures require payment in advance. Under these circumstances we will have verified your approximate responsibility with your insurance company. We require a 24 hour notice when canceling or rescheduling an appointment. Our providers are very much in demand therefore you will be charged if you do not show for an appointment. Please remember to give 24 hour notice when canceling or rescheduling an appointment. You will be billed for a no show. We will be happy to answer any questions you may have regarding our financial policy Patient Signature: Date:
Patient Communication Preferences
Patient Name Date of Birth Address City State Zip Cell Phone Home Phone Work Phone Email Marital Status Gender Race Ethnicity Employer Name Occupation Emergency Contact Name Phone Relationship Local Pharmacy
Patient Information Sheet. Spouse Information. Emergency Contact Information. Referral. Insurance Information
Patient Information Sheet Patient of Birth Patient Social Security # Street Address City, State & Zip code Home Phone Cell Phone Work Phone Email Address Pharmacy Address/Phone: Patient Employer Address
Please return paperwork to our office: Rogue River Family Practice Clinic (Mailing) P.O. Box 1020 (Physical) 509 E. Main St. Rogue River, OR 97537
WELCOME Thank you for choosing Rogue River Family Practice Clinic to serve your medical needs. Please complete the enclosed registration packet as soon as possible so that we can get your record established
PATIENT INFORMATION. PRIMARY INSURANCE Ins Co. Name: PRIMARY POLICYHOLDER PARENT/GUARDIAN INFORMATION (REQUIRED IF PATIENT UNDER 18 YEARS OF AGE)
PATIENT INFORMATION Name: Sex: of Birth: Social Security #: Address: Apt # City: State: Zip: Primary Phone: Primary Phone Type: Cell Home Work Secondary Phone: Secondary Phone Type: Cell Home Work Email:
ANNUAL WELLNESS AND PREVENTATIVE EXAMS
ANNUAL WELLNESS AND PREVENTATIVE EXAMS INFORMATION REGARDING BILLING AND INSURANCE Due to changes in health care laws, we are required to distinguish and bill separately for annual wellness exams and new
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Last Name: First Name: MI: Status: SIN MAR WID DIV Address: Home Phone : Cell Phone: Work Phone: DOB: Age: Email Address: How Did You Find Out About Us? Friend/Family Co- Worker
Total Care Family Practice 1701 N Green Valley Pkwy Bldg 5-C Evan C. Allen, MD Henderson, NV PH: (702) Fax: (702)
Demographics Last : First : What would you like to be called: Marital Status: Single Married Other Gender: Male Female DOB: Social Security: Email: Address: City: State: Zip Code: Home Ph: Cell Ph: Employment
NOWOBILSKA MEDICAL PRACTICE PATIENT REGISTRATION FORM 4201 West 95 th Street Oak Lawn, IL 60453
NOWOBILSKA MEDICAL PRACTICE PATIENT REGISTRATION FORM 4201 West 95 th Street Oak Lawn, IL 60453 Please Print: Patient Name. First MI Last Address: City: State: Zip: Home Phone: Work Phone: Cell: Email
WIMBERLEY MEDICAL CLINIC
WIMBERLEY MEDICAL CLINIC PATIENT INFORMATION Patient Information Name: Date of Birth: SSN: Mailing Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Sex: M F Race: Caucasian Black or African
SKINNER FAMILY PRACTICE 1
SKINNER FAMILY PRACTICE 1 Health History Patient Name: DO YOU HAVE A PERSONAL HISTORY OF DIABETES (E11.9) COPD (J44.9) BLOOD PRESSURE (I10) CROHNS DISEASE (K50.10) HEART DISEASE (I51.9) TUBERCULOSIS (A15.9)
NOTICE TO OUR PATIENTS
NOTICE TO OUR PATIENTS Although we participate with most insurance plans, you as the patient and/or insured party are responsible for co-pays, deductibles and any non-covered services, which are outlined,
To: Our Medicare Patients Re: Medicare Annual Wellness and Other Preventive Visits
To: Our Medicare Patients Re: Medicare Annual Wellness and Other Preventive Visits Beginning January 1, 2011 Medicare began covering an Annual Wellness Visit in addition to the one-time Welcome to Medicare
CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.
PATIENT INFORMATION First Name: Middle Initial: Last Name: Mailing Address: Street Address: City: County: State: Zip: Phone #: Work: Ext: Would you like us to text you? Yes No Cell #: Driver s License
PATIENT REGISTRATION / INFORMATION SHEET
PATIENT REGISTRATION / INFORMATION SHEET Name: LAST FIRST MIDDLE Date of Birth: Gender: M F Marital Status: Social Security Number: Email Address*: Street Address: City: State: Zip: Home Phone: Cell Phone:
PATIENT INFORMATION EMERGENCY CONTACT
Phone (614) 682-5095 Fax: (614) 891-6533 www.ohioplasticsurgeryspecialists.com PATIENT INFORMATION Name Birth Date Age (First, Middle Initial, Last) Address City State Zip Home Phone ( ) Work Phone ( )
PATIENT INFORMATION. Caucasian or White Male Female. Unknown IN CASE OF EMERGENCY
Name (Last, First, Middle Initial): PATIENT INFORMATION Salutation: Mr. Social Security # Preferred Language: Race: Ethnicity: American Indian or Alaska Native Hispanic or Latino Asian Not Hispanic or
Welcome to the ACCESS OMNICARE NEW INJURY PATIENT Your Occupational Medicine partner in Health and Safety
A. Patient Information Please complete this document and return it with your Driver s License LAST NAME: FIRST NAME: MIDDLE NAME: PREFERRED NAME: SEX: DATE OF BIRTH: SOCIAL SECURITY NUMBER: FORMER LAST
Conway Regional After Hours Clinic
Conway Regional After Hours Clinic Patient Information Patient Name: Date of Birth Sex (M) (F) SS# Marital Status M S W D Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Mailing Address: Street City
Home Phone Work Phone Cell Phone In the event of an emergency, who should we contact? Name Relationship Emergency Contact Phone
Roosevelt Dental, P.A. Gene Kim, d.d.s. WELCOME Thank you for selecting Roosevelt Dental. To help us best meet your health care needs, please complete this form as accurately as possible. Thank you. This
PATIENT INFORMATION:
ALLISON SHIGEZAWA MD PATIENT REGISTRATION Today s Date: PATIENT INFORMATION: Patient Name: Patient Street Address Apartment City State Zip Code Home Telephone Number: Sex: Female Male Work: Cell Number:
Sammy Lerma III, M.D. P.A. History and Physical Name: DOB: Age:
History and Physical Name: DOB: Age: Reason for Visit : Current Medications: Previous Hospitalizations: Last Physician's Name: Previous Surgeries: Reason for Changing Physicians: Current Specialists: Medication
WELCOME TO OUR PRACTICE
Obstetrics Gynecology WELCOME TO OUR PRACTICE As a service to you Partridge Creek Obstetrics Gynecology participate with Medicare, Blue Cross and many insurance plans. We will submit claims to your insurance
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION Patient s Name Sex Male Female Date of Birth Address City/State Zip Code Home Phone Cell Phone E-mail address Driver License # Marital
Is a 3 rd party settlement anticipated (lawsuit, auto accident, etc)? Yes No
PATIENT INFORMATION Patient Name Date of Birth Home Address Soc. Sec. No. Home Phone Work Phone Email Cell Phone Physician Date of Surgery Date of injury/flare up Cause Date of next Dr. appt. Referred
KRAIG R. PEPPER, D.O. P.A.
Thank you for choosing Dr. Kraig Pepper, D.O. P.A. for your care. The following is required to provide you with the quality medical care. The doctor and staff will review this information and place it
FAMILY HISTORY CHILD/CHILDREN S NAME:
FAMILY HISTORY CHILD/CHILDREN S NAME: FAMILY HISTORY (THINK IN TERMS OF THE CHILD S SIBLINGS, PARENTS, GRANDPARENTS, AUNTS, UNCLES AND FIRST COUSINS): ANY ALLERGIES, HAY FEVER, ASTHMA OR ECZEMA? WHO? ANY
PATIENT REGISTRATION
7521 Virginia Oaks Drive #240 Gainesville, VA 20155 Ph: 703-753-7600 PATIENT NAME (FIRST, MIDDLE, LAST) PATIENT REGISTRATION DATE: HOME PHONE HOME ADDRESS CELL PHONE CITY STATE ZIP CODE SOCIAL SECURITY
Villa Medical Arts New Patient Forms
Villa Medical Arts New Patient Forms New Patients, To expedite your check- in process, please print and complete the following pages. If you have access to a fax machine, please fax them along with a copy
Continued on Reverse Side
PATIENT REGISTRATION FORM Date Male Female First Middle Last Email Address Mailing Address City State Zip Code Home Phone Work Phone Cell Phone Social Security Date of Birth Ethnicity: Hispanic or Latino
Obstetrics and Gynecology 50 Medical Drive Suite 100 (806) Borger, TX
PATIENT INFORMATION First Name MI Last Name Date of Birth Age: Social Security # Race Ethnicity: Sex: Female / Male Marital Status: S M W D Email Address: Mailing Address City State Zip Physical Address
Patient Information. State Zip Home Phone Cell Phone
Patient Information Last Name First Name Middle Initial Street Addresss City State Zip Home Phone Cell Phone Can we call you at work? Work Phone Date of Birth Social Security Number* * Because we extend
Health History Questionnaire
Health History Questionnaire New Patient Return Patient A) NAME Age DOB 1. Marital status: Single Married Long-term relationship Divorced Widowed 2. Reason for this visit: Referring physician: 3. Occupation:
Nadine Antonelli, MD 1500 Medical Center Drive Wilmington, NC Phone: Fax:
Add to Cancellation list Yes No Patient Information Patient Name: DOB: AGE: SS#: Primary Phone: Current Address: City: State: Zip: Email: Other Phone: Other Phone: Employer/School Name: Employment / School
Northwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR
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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
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION PATIENT Last Name First Name Email Address FIT Box Address City INSURED PARTY Company Policy No. Group No. Policy Holder Policy Holder DOB Phone State ZIP Cell or Home Phone Student
Medical History Patient Information : Name DOB Age Ht: ft. in Wt: lbs. Gender: Marital Status Procedure(s) you are considering:
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby give my consent for Dr. Marisa Lawrence to use and disclose protected health information (PHI) about me to carry out treatment,
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:
Christine LaComb, RN, FNP-C th Street Suite B Groves, TX (409) Phone (409) Fax
Christine LaComb, RN, FNP-C 6000 39 th Street Suite B Groves, TX. 77619 (409) 962-8509 Phone (409) 962-0763 Fax Welcome To Our Practice! In Order To Properly Serve You, Please Complete The Following Forms
3. Should you be unable to keep your appointment, please call us at (209) to cancel or reschedule, as soon as possible.
To Our Patients, Welcome to the family practice office which has served Ripon and surrounding communities since the early 1970 s. We look forward to providing you with quality medical care. The following
Denny Eye & Laser Center Kevin Denny, MD Young Choi, OD Joy Ohara, OD
Kevin Denny, MD Young Choi, OD Joy Ohara, OD PATIENT REGISTRATION NAME: ADDRESS: SEX: male female LAST FIRST MIDDLE INITIAL NO. AND STREET CITY STATE ZIP ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL
Patient Name: M F LAST FIRST MI. Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( )
Ahwatukee Family Medical Center Patient Information Date: Patient Name: M F LAST FIRST MI Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) EMAIL: Date of Birth: / / SS# Marital Status:
Name: Last Name First Middle Initial. Date of Birth: Age: Sex: SS#: DL#: Home Address: Cell #: Home#: Work#:
Name: Last Name First Middle Initial Date of Birth: Age: Sex: SS#: DL#: Home Address: Cell #: Home#: Work#: Email Address: @ Occupation: Work address: Nearest Relative Living with You: Phone#: (Or nearest
Regain Natural Hormone and Wellness Center
Regain Natural Hormone and Wellness Center Name: Today s Date: Date of Birth: Age: Height: Weight: Street Address: City: State: Zip: Phone Numbers: Home: Cell: Email Address 1 Email Address 2 Employed
NEW PATIENT REGISTRATION
NEW PATIENT REGISTRATION Today s Date: Patient s Last Name First Name: Mid. Initial: Date of Birth Age: Sex: F M Marital Status: S M D W Patient s Social Security Number Driver s License No. Home/Mailing
Home Address: Sex: Male Female. Primary Care Physician: Phone Number: ( ) - Cardiologist: Phone Number: ( ) - Emergency Contact: Phone Number: ( ) -
Today s Patient Name: Marital Status: SSN: Home Address: Sex: Male Female Zip Home Phone: Cell Phone: Email: Referred by: Primary Care Physician: Phone Number: ( ) - Cardiologist: Phone Number: ( ) - Emergency
PATIENT DEMOGRAPHICS. Primary Insurance: Policy #: Group #: Secondary Insurance: Policy #: Group #:
TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:
Greenbriar Vision Center Welcomes You Please Print Clearly
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Willow Bend OB/GYN Obstetrics, Gynecology & Infertility
Dear Patient, Welcome to our medical office. We look forward to meeting you soon. In order to provide you with the best possible care, please complete our registration forms prior to your first visit and
Patient Registration. Patient Information. Guarantor Information (skip if same as patient) Emergency Contact Information. Insurance Information
Patient Registration Patient Information Patient name (Last, First) Patient date of birth Patient gender (M / F) Patient marital status Mailing address (address number & street) Patient Social Security
INDIVIDUAL HEALTH INSURANCE APPLICATION
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HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN (317)
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North Shore Fertility, S.C. Infertility History Form
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PRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip:
PRINT CLEARLY NEW PATIENT FORM Name: (first) (last) (m.i) Address: City: State: Zip: Email: Sex: Male Female Student Yes No Home Ph: Cell Ph: Work Ph: Fax: Age: Of Birth: Statement Preference: E-mail Fax
Personal Medical History Form Please Print
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PATIENT REGISTARTION
PATIENT REGISTARTION Patient Name: Last First MI Address: City: State: Zip Code: Tel # (h): Tel # (w): Cell #: S.S. #: DOB: Age: Email address: Male: Female: Marital Status Spouse or Parent Name Race Preferred
MACRI DENTAL LLC 4380 S. Syracuse St. Suite 502 Denver, CO Patient Registration Form
Personal Information Patient Registration Form Responsible Party First Name Initial Last Name Patient First Name Initial Last Name Address City State Zip Home Phone Work Cell Birthday Social Security Email
Arizona State Urology, PLLC (Subsidiary of Glendale Urology, PC)
Arizona State Urology, PLLC (Subsidiary of Glendale Urology, PC) PATIENT REGISTRATION PLEASE PRINT AND COMPLETE ALL ENTRIES PATIENT NAME (LAST -- FIRST -- MIDDLE INITIAL) CITY, STATE ZIP HOME PHONE CELL
Patient Information. Primary Care Physician: Last Name: First Name: MI: Address: City/ST/Zip code: Home Phone :( ) Cell Phone: ( ) Leave Message
Patient Information Last Name: First Name: MI: Address: City/ST/Zip code: Primary Insurance: Policyholder: DOB: / / SSN: Group ID #: Individual ID #: Home Phone :( ) Leave Message Cell Phone: ( ) Leave
Employed Unemployed Retired Student Full Time Part Time Employer Name: Employer Phone #: Occupation:
Marietta Office Towne Lake Office Patient Registration Form DATE / / Physician (Please check one) Dr. Kelley Dr. Huffman Dr. Windom Dr. Chappell Dr. Tackitt Dr. Killian When calling for today s appointment:
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 (
Doc Bresler s Cavity Busters - New Patient History Form
Doc Bresler s Cavity Busters - New Patient History Form Patient s Name Nickname Date of Birth Age Female Male Address City,State,Zip Code Home Phone Mother s Name Occupation Email Address Cell Phone Father
Welcome serve-you-rx.com
Serve You Custom Rx Management is a national Pharmacy Benefit Manager that your organization has selected to provide a pharmacy benefit to you and your covered family members. We offer a wide array of
COLLAR CITY PODIATRY
Richard Altwerger, DPM COLLAR CITY PODIATRY PATIENT INFORMATION FORM Timothy Fauler, DPM Name: Email PATIENT INFORMATION Date of Birth: Sex: M F Marital Status: City: State: Zip: Home Phone: Cell Phone:
HIGHLAND PARK FAMILY PRACTICE, LLC ARTHUR H. MILLER MD, FAAFP 505 RARITAN AVENUE HIGHLAND PARK, NJ TEL:
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Medical Information Sheet
Medical Information Sheet Name: Date: Age: Sex: M F Height: Weight: Dominant hand: R L Occupation: Presently working: Y N Reason for being seen today: Date of Onset: Involved side: R L Both Describe any
Patients who are running 20 minutes late for his/her scheduled appointment will be rescheduled to the next available appointment/ day.
Orthotics/ Durable Medical Equipment Policy H2T is NEVER able to guarantee payment by medical insurance carriers for Orthotics and/or Durable Medical Equipment. H2T will bill your medical insurance as
LAS VEGAS ENDOCRINOLOGY
Today s Date: Primary Care Provider: Patient Information Last Name: First Name: Date of Birth: Sex: M F Social Security #: Street Address: City: State: Zip: Occupation: Employer: Home Phone: Cell Phone:
ARE YOU CURRENTLY PREGNANT: Yes No
PATIENT REGISTRATION FORM Last Name (Print) (First) (MI) (Previous/Maiden) Social Security# DOB Marital Status: Single Married Divorced Sep. Widow Address City State Zip Home# Work# Ext Cell# Circle best
Patient Registration Form 8/12/2014 PATIENT INFORMATION (Person seeing the Doctor today) Last Name First Name Middle Initial
Patient Registration Form 8/12/2014 PATIENT INFORMATION (Person seeing the Doctor today) Last Name First Name Middle Initial Janis Black, D.O. Family Health Center at Port St. John 3740 Curtis Blvd, Suite
X Signature of Patient or Patient Representative Date Relationship of Patient Representative to Patient
Welcome to our office. Please complete this form to the best of your knowledge. GENERAL INFORMATION: Today s Date / / Patient Name: First Middle Last How do you wish to be addressed? (e.g. - Mr., 1st Name,
New Patient Referral and Insurance Verification Form
New Patient Referral and Insurance Verification Form Today s Date: Prior Patient: Y N How did you hear about our practice? Physician: Dr., Internet:, Family/Friend:, Advertising:, Insurance:, Other:. Patient
ERIC ROCKMORE, DPM, FACFAS
Date: Name Date of Birth Address City State Zip Code Email Address Preferred Language Social Security(Medicaid only) Referred by Gender Race Ethnicity Home# ( ) Work # ( ) Cell ( ) Preferred phone # (
Patient Registration Form This form is posted on our website
Patient Registration Form This form is posted on our website www.kidseyecare.net Caring For the Vision of Our Future Patient Last Name: First Name: Sex : Male / Female Date of Birth: SS #: - - Phone: (
**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
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
I Federal Law requires us to ask race: Hispanic Non-Hispanic
Today's Date < McCoy VISION Please Contact Me at this Number Patient Registration Chart# - Patient's Name (last, first, middle initial) Date of Birth Sex Home Phone Street Address City State Zip Work
HOLSTON MEDICAL GROUP Multi-Specialty Physician Practice
HOLSTON MEDICAL GROUP Multi-Specialty Physician Practice 105 West Stone Drive, Suite 4-C Kingsport, TN 37660 Telephone (423) 578-1595 Facsimile (423) 578-1596 Gastroenterology Lawrence Bailey, Jr., MD
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
Last Name: First Name: MI: Address: Apt #: City: State: Zip: Home #: Work #: Emergency #: Birthdate: SSN: Sex: Marital Status: Employer: Occupation:
Patient Registration How did you hear about us? Newspaper Friend/Family Website Other: Patient Information Last Name: First Name: MI: Address: Apt #: City: _ State: Zip: Home #: Work #: Emergency #: Birthdate:
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:
Carter Family Dentistry
Carter Family Dentistry General Dentistry Patient Information Patient Name: Date: Last First MI Occupation: Employer: Title/Pos. 1 Male 1 Female 1 Single 1 Married 1 Child 1 Other Spouse s Name Social
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#:
New Patient Registration Form. New Patient Update Date: / /
New Patient Registration Form New Patient Update Date: / / Children s Names Gender Birthdate Race* Ethnicity *Race = White American, Native American, Alaska Native, Asian American, Black or African American,
AUBURN URGENT CARE. Patient Information. Name: Last First Middle. Permanent Address: Apt #: Zip: City: State: Employer: Phone: ( )
AUBURN URGENT CARE Patient Information Name: Last First Middle Date of Birth: / / Social Security: Permanent Address: Apt #: Zip: City: State: Race: Gender: M F Undifferentiated Home Phone: ( ) Cell:(
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
New Child Registration
New Child Registration Date: / / Insurance Information Primary insurance Primary Reason for today s visit: Last Name, First, MI Mailing address City, State, ZIP Which pharmacy do you use? Insurance Co.
Consent Release Form for Medical Information
Consent Release Form for Medical Information Patient Name: (Please print patient name) Date of Birth: Doctor: Internist/Family Practice Physician: (First name) (Last name) Telephone #: Preferred Pharmacy
PATIENT DEMOGRAPHICS. Name: Age: Sex: Social Security: Address: Marital Status: Emergency Contact: Emergency Tel: How did you hear about the office?
PATIENT DEMOGRAPHICS MRN: Date: Name: Age: Sex: Social Security: Email: DOB: Address: Marital Status: Home Phone: Cellphone: Emergency Contact: Emergency Tel: How did you hear about the office? Preferred
PATIENT INFORMATION. Name Date Address Phone City State Zip Code Occupation Work Phone Date of Birth Soc. Sec. Num.
PATIENT INFORMATION Name Address Phone City State Zip Code Occupation Work Phone of Birth Soc. Sec. Num. Cell Phone Email Married Single Domestic Partner Other: Spouse/Partner Phone Occupation Work Phone
Appointment Confirmation Policy
Appointment Confirmation Policy Our Office strives to be respectful of each patient s time. When patients do not show up for their scheduled appointments or are late to notify our office of a cancelation,
Patient Name: Todays Date: Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status
Patient Name: Todays Date: *General Patient Information Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status Email Phone: Home ( ) - Cell ( ) - Mailing- Address, City, State & Zip *PARENT
Michael A. Bogdan, MD, MBA, FACS
Michael A. Bogdan, MD, MBA, FACS Health History Identification Age Height Weight Please Print your full Name Reason for Consultation Age: Allergies Please check: No Known Drug Allergies No Known Food Allergies
SOUTH SHORE NEPHROLOGY, P.C.
SOUTH SHORE NEPHROLOGY, P.C. Please fill out this form along with all the documents included in the patient packet and bring it with you for your upcoming appointment. Be sure to bring your insurance card(s)
Prairie Life Chiropractic 1224 S. Main Ave. Sioux Center, IA 51250
Patient Information Name Birth Date Guardian s Name (If applicable) Address City State Zip Home Phone ( ) Cell ( ) Email Sex: Age SS# Race: Ethnicity: Occupation Employer Employer City Employer Phone(
Patient Registration Form
I Patient Registration Form Please Print Clearly and Fill in All the Blanks PATIENT INFORMATION First Name: Middle Initial: Last Name: DOB: Age Address: Apt #: City: State: Zip: SSN: Driver License Number:
PATIENT REGISTRATION
PATIENT REGISTRATION PLEASE PRINT and be sure to complete the entire form and bring with you to your eye exam. Last Name First Name Middle Name Email Address Date of Birth Age Sex Home Address Street City
Welcome to Hawaii Women s Healthcare
Cheryl Lynn T. Rudy, M.D. Cheryl L. Leialoha, M.D. Erin C. Gertz, M.D. Laura A. Spector, D.O. Andrea Wieland, APRN Welcome to Hawaii Women s Healthcare Hawaii Women s Healthcare strives to provide you
NEW PATIENT INFORMATION FORM Michael Metzger MD Charles Harring MD Andres Ruiz MD Gustavo Cardenas MD Heidi Templin ARNP
NEW PATIENT INFORMATION FORM Michael Metzger MD Charles Harring MD Andres Ruiz MD Gustavo Cardenas MD Heidi Templin ARNP Patient name: Today's Date: / / First Last Referred by: Primary care physician: