Last Name First Name Middle Initial. Address City State Zip Code. Date of Birth Social Security. Home Number Cell Phone. Employer Work Number.
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- Terence Samson Dickerson
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1 Last Name First Name Middle Initial Address City State Zip Code of Birth Social Security Home Number Cell Phone Employer Work Number Insurance Company Policy Holder's Name: If you are not the policy holder, what is your relationship to them? Policy Holder DOB SSN# Emergency Contact Name Relationship Contact Number Primary Doctor Referring Doctor Parents Name if Minor DOB SS# May we leave a voice mail on your answering machine? Yes _ No May we contact you by: Cell phone Yes _ No _ or Yes _ No _ We may impose a return check fee of $25.00 if any check or electronic payment authorization you provide as payment on your account is not honored upon first presentation. By signing below, I authorize the release of any medical information necessary to process my claim. I also authorize payment of medical benefits to the physician or supplier of service as indicated on the claim. In the event it is necessary to refer my account to a collection agency or an attorney, I agree to pay all collection costs, including attorney fees and court costs. By signing below, I authorize The Women s Center to call me, me, and/or text message me in order to contact me. I understand it is my responsibility to update my contact information with the care center in the event that it changes after an appointment. ATTENTION PATIENTS: Labs, pap smears and biopsy fees are NOT included in the office charge and you will be billed separately by the laboratory. It is your responsibility to know your coverage. If you are unsure of any aspect of your insurance coverage, please call the member services number on the back of your insurance card. The member services representative will be able to assist you with any questions you may have. Our office utilizes an automated collections system. If you have not set up a payment plan or paid your balance within 120 days (approximately 4 statements) your account will be sent to collects and we will not be able to see you. It is your responsibility to contact us if you have any questions about a statement you receive. Once your account is sent to collections, no changes can be made to the balance. Print Name Patient Signature
2 Dear Patient, Under the Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for Medical Malpractice. Your obstetrics and gynecology physician has decided not to carry medical malpractice insurance. This is permitted under the Florida Law subject to certain conditions. Florida law imposes strict penalties against non-insured OB/GYN physicians who fail to satisfy adverse judgment arising from claims of medical malpractice. This notice is provided to you pursuant to Florida Law. If you have any hesitations, please speak with any of our staff members. Sincerely, The Women's Center I have read and understand that this office does not carry malpractice insurance. Signature Print Name Witness Signature
3 HIPPA Notice of Privacy I, _ have read the HIPPA Notice of Privacy Practices. Please list any persons that you authorize our practice to speak with regarding your medical health information. We will not give out information to anyone whose name does not appear below. You have the right to change this authorization at any time, however, additions to this list must be made in person at one of our seven locations. Patient Signature
4 I acknowledge that I have read and received a copy of The Women's Center practice guidelines as it appears below and agree to follow those guidelines. _ Patient Signature Practice Guidelines Dr. Douglas E. Gearity, M.D. & Associates would like to welcome you to our practice and are pleased that you have chosen us for your care. We are a patient oriented office; committed to providing the highest standards of care possible. Our friendly, well-trained staff is here to serve your needs. We accept many different insurance plans; commercial, medicaid and Tricare military. We are not in network with medicare. We currently have multiple locations throughout the Central Florida area to accommodate our patients which include: Hunter s Creek, Downtown Orlando, St. Cloud, Ocoee, Oviedo, Celebration and Altamonte Springs. We see patients by appointment only, 7:30am-5:00pm Monday through Saturday. For after-hours, please call and follow our automated system instructions. Once your appointment is scheduled, you will receive a confirmation call 48 hours before. If you have a privacy detector on your phone, you will not receive the confirmation call through our automated service. In the event that you must cancel or reschedule, or if you are running late to your appointment, please call our offices so that we are able to make the necessary adjustments in our patient schedule. If you are more than fifteen minutes late, you may have to reschedule for another day. Should you request your medical records, there is a charge of $1.00 per page up to $ The release of records directly to another physician is free of charge. It may take up to 72 hours to prepare and release your records. Records release forms are available on our website and should be ed to medicalrecords@wcorlando.com. If you are in need of Family Medical Leave Act (FMLA) forms, disability verifications or other paperwork, there is a $20 charge per form that is to be processed. FMLA forms should be ed to FMLA@wcorlando.com. At your first visit, a review of your medical history will be completed by one of our providers. We will offer advice based on our findings and answer any questions you may have. If you require additional testing, it will be ordered at the time of your visit. It is our office policy that you may make a follow-up appointment to review any medical findings including lab results. The provider will also discuss an appropriate plan of treatment with you during this appointment and insurance will be charged for that visit. After your visit, if you have a medically related question, please askanurse@wcorlando.com. Your insurance policy may require an office visit co-payment; that amount is due in full at the time of your visit. Per your insurance company: Benefits are quoted as an estimate only and are not a guarantee of payment. Final determination will be made by your insurance carrier once the claim is received. Self-pay patient office fees are also due in full at the time of service. Labs incurred during your visit will be billed separately from the lab and are not included in our fees. Under the Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for Medical Malpractice. Your obstetrics and gynecology physician has decided to not carry medical malpractice insurance. This is permitted under the Florida law subject to certain conditions. Florida law imposes strict penalties against non-insured OB/GYN physicians who fail to satisfy adverse judgment arising from claims of medical malpractice. This notice is provided to you pursuant to Florida Law. Our success can only be measured by your satisfaction with the health care you receive. We welcome your comments as to how we may, in any way, satisfy your medical needs. Please give us your thoughts at comments@wcorlando.com. Thank you for choosing The Women s Center for your healthcare needs.
5 Patient Copy Please retain for your records Dr. Douglas E. Gearity, M.D. & Associates would like to welcome you to our practice and are pleased that you have chosen us for your care. We are a patient oriented office; committed to providing the highest standards of care possible. Our friendly, well-trained staff is here to serve your needs. We accept many different insurance plans; commercial, medicaid and Tricare military. We are not in network with medicare. We currently have multiple locations throughout the Central Florida area to accommodate our patients which include: Hunter s Creek, Downtown Orlando, St. Cloud, Ocoee, Oviedo, Celebration and Altamonte Springs. We see patients by appointment only, 7:30am-5:00pm Monday through Saturday. For after-hours, please call and follow our automated system instructions. Once your appointment is scheduled, you will receive a confirmation call 48 hours before. If you have a privacy detector on your phone, you will not receive the confirmation call through our automated service. In the event that you must cancel or reschedule, or if you are running late to your appointment, please call our offices so that we are able to make the necessary adjustments in our patient schedule. If you are more than fifteen minutes late, you may have to reschedule for another day. Should you request your medical records, there is a charge of $1.00 per page up to $ The release of records directly to another physician is free of charge. It may take up to 72 hours to prepare and release your records. Records release forms are available on our website and should be ed to medicalrecords@wcorlando.com. If you are in need of Family Medical Leave Act (FMLA) forms, disability verifications or other paperwork, there is a $20 charge per form that is to be processed. FMLA forms should be ed to FMLA@wcorlando.com. At your first visit, a review of your medical history will be completed by one of our providers. We will offer advice based on our findings and answer any questions you may have. If you require additional testing, it will be ordered at the time of your visit. It is our office policy that you may make a follow-up appointment to review any medical findings including lab results. The provider will also discuss an appropriate plan of treatment with you during this appointment and insurance will be charged for that visit. After your visit, if you have a medically related question, please askanurse@wcorlando.com. Your insurance policy may require an office visit co-payment; that amount is due in full at the time of your visit. Per your insurance company: Benefits are quoted as an estimate only and are not a guarantee of payment. Final determination will be made by your insurance carrier once the claim is received. Self-pay patient office fees are also due in full at the time of service. Labs incurred during your visit will be billed separately from the lab and are not included in our fees. Under the Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for Medical Malpractice. Your obstetrics and gynecology physician has decided to not carry medical malpractice insurance. This is permitted under the Florida law subject to certain conditions. Florida law imposes strict penalties against non-insured OB/GYN physicians who fail to satisfy adverse judgment arising from claims of medical malpractice. This notice is provided to you pursuant to Florida Law. Our success can only be measured by your satisfaction with the health care you receive. We welcome your comments as to how we may, in any way, satisfy your medical needs. Please give us your thoughts at comments@wcorlando.com. Thank you for choosing The Women s Center for your healthcare needs.
By signing this form, I acknowledge that I have been advised of all applicable policies. Patient Signature. Patient Name (printed) Witness Signature
5000 Brittonfield Parkway* Suite A 128 (315) 446-4400 phone * (315) 446-4201 fax By initialing below, I am indicating that I have been given an opportunity to read the policies, relevant to me, set forth
PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code:
PATIENT INFORMATION PATIENT INFORMATION First Name: Last Name: Middle Initial: Nickname: Date of Birth: Sex: Marital Status: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: How did you hear
Premier Obstetrics and Gynecology
, FL 33607, FL 33635 Patient General Information Name Birth date Age Social Security # Drivers License Home # Cell # Work # Street Address City State Zip Code Email Address Occupation Employer Spouse s
We are limited, not by our abilities, but by our vision.
We are limited, not by our abilities, but by our vision. WELCOME Thank you for choosing Advanced Eye Care Center as your eye healthcare provider! On behalf of Dr. Lawrence Shafron, Dr. Rodgers Eckhart,
Clinic Hours Monday Friday 7:00 AM 4:00 PM (end times may vary); Select Saturdays (by appointment)
Thank you for scheduling an appointment with Clinical Neurology Specialists West. Following is some information that will help familiarize you with our practice. Patient Education / Physician and Provider
(First) (MI) (Maiden) (Last) Social Security #: - - Birthdate: / / Age: Complete Address: City: State: ZIP: -
TODAY S DATE: COLUMBUS OBGYN SPECIALTY CENTER, PLLC PATIENT INFORMATION SHEET Chart #: Office Use PATIENT S LEGAL NAME: (First) (MI) (Maiden) (Last) Social Security #: - - Birthdate: / / Age: Marital Status:
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION RECORD (Please Print or Write Legibly) DATE ACCT # PATIENT INFORMATION NAME First Middle Init. Last MAILING ADDRESS CITY STATE ZIP SEX RACE Ethnicity: q hispanic/latino q Not Hispanic/Latino
NEUROLOGICAL INSTITUTE OF MICHIGAN PATIENT INFORMATION FORM
NEUROLOGICAL INSTITUTE OF MICHIGAN PATIENT INFORMATION FORM PATIENT NAME: HOME ADDRESS: BIRTH : SSN#: CELL: HOME TELEPHONE: EMPLOYER: WORK: EMERGENCY CONTACT: REFERRING DOCTOR: PRIMARY CARE MD: PHONE:
NEW PATIENT DEMOGRAPHICS
NEW PATIENT DEMOGRAPHICS Name PATIENT Date: PARTNER Street Address City, State, Zip Social Security # Date of Birth Home Phone# Cell Phone # Work Phone # Email Address Occupation Employer Primary Insurer
BILL L. JOU, M.D., INC.
BILL L. JOU, M.D., INC. AUTHORIZATION TO TREAT I (and/or the undersigned on behalf of the patient) voluntarily consent to allow Dr. Bill L. Jou and staff to provide such evaluation and/or care and treatments
Center of Excellence in Spinal Care. Patient Information. If Patient is a minor Guarantor Name: If Patient is a minor Guarantor Social Security #:
Center of Excellence in Spinal Care Patient Information Patient Name: Patient Date of Birth: Today s Date: Current Age: Sex (Circle One) Male Female Patient Social Security Number: If Patient is a minor
TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: _ Primary Care Physician: _
TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: Primary Care Physician: Patient s LEGAL Last name: First: Middle Initial: Patient date
If you are already an established patient of either Dr. Aroesty or Ms. Corrice, you do not have to reregister or fill out any additional paperwork.
To Our New Patient: Our staff would like to take this opportunity to welcome you to Garden State Snoring Solutions, LLC. It is our goal to make your visit with us as pleasant and comfortable as possible.
Medication History (List all medications that you currently take with the dose)
All Women OB/GYN, P.S.C. 4010 Dupont Circle, Suite L-07 Louisville, KY 40207 (P) 502.895.6559 (F) 502.895.8994 Lisa Crawford, MD Amy Deeley, MD Elena Salerno, MD Aimee Paul, MD Tanika R. Taylor, MD Rachel
Annual Exam Welcome Back!
Annual Exam Welcome Back! Name: Date: An annual exam is preventative care consisting of a physical exam and possibly a Pap smear. If you have problems to discuss with the physician or nurse practitioner,
Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.
Today s Date Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.H NAME OF PATIENT (CHILD) DOB SSN of child SEX
Bergen County Gynecology, P.C.
PATIENT INFORMATION LAST NAME FIRST NAME MIDDLE MAIDEN NAME (IF ANY) DATE OF BIRTH SS# PLACE OF BIRTH MARITAL STATUS RACE ETHNICITY PREFERRED LANGUAGE OTHER LANGUAGES SPOKEN ADDRESS CITY ST ZIP HOME PHONE
Gastroenterology Specialists of Delaware, LLC
Gastroenterology Specialists of Delaware, LLC George Benes, M.D. Michael J. Brooks, MD As a patient of GI Specialists of DE, I understand that there may be occasions where the office staff may need to
Policies and information:
Policies and information: Basic Policies: Please be on time for your appointments. If you are late for your scheduled appointment, there is a chance that you will be rescheduled. We require at least 24
PATIENT INFORMATION Date Patient last name Patient first name Patient middle name. Primary Address City State Zip. Alternate Address City State Zip
Clinic Name: The Mollen Clinic Physician/Provider being seen today: Arthur Mollen, DO, Martin Mollen, MD, Melvin Bottner, MD, Monika Sajecki, PA, Kaitlin Kramer, PA PATIENT INFORMATION Date Patient last
Catherine A. Casteel, DPM 7501 Lakeview Parkway, Ste. 135 Rowlett, TX Phone Fax
Catherine A. Casteel, DPM Authorization to Leave a Voicemail Please provide number(s) ONLY IF you approve us to leave DETAILED information related to appointments, billing, test results, diagnosis, and
WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely.
Page 1 of 4 WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely. Date: Dr: Chart #: Patient s Name: First MI Last Patient s
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
Last Name First MI. SSN # DOB Age Sex M F. Home Address. City State Zip
Klein & Associates, M.D., P.A. Registration Form Last Name First MI SSN # DOB Age Sex M F Home Address City State Zip Cell ( ) Home Phone ( ) May we leave a detailed message on your voicemail for the numbers
Prefix Last First Middle Suffix. Maiden Gender SSN Marital Status Date of Birth
Prefix Last First Middle Suffix Maiden Gender SSN Marital Status Date of Birth Race Ethnicity Primary Language Address Line 1 Address Line 2 United States Zip City State Country Home Phone Cell Phone Work
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
PATIENT REGISTRATION
First Name Middle Name Last Name Preferred Name PATIENT REGISTRATION Patient Information Byron C. Cotton, M.D., FAAP Gayla Woodson, MSN, CPNP First choice for infants thru young adult! First Patient Second
I am looking forward to meeting you and helping you attain your best health possible!
Dear New Patient, Danielle E. Weiss, MD, FACP Center for Hormonal Health and Well-Being 477 N. El Camino Real, Suite D200, Encinitas CA 92024 760-262-7104 (Office hours) 760-753-3636 (Outside office hours)
Lake County Neuromonitoring, LLC Libertyville, Illinois Lake County Imaging, LLC P: Lakeshore Physical Therapy, LLC F:
Section A: Patient Information Name: Today s Date: Telephone #: (H) (C) (W) Preferred method of contact: Home Cell Work Marital Status: Single Married Other Home Address: City/State/ZIP Date of Birth:
REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:
: REGISTRATION FORM Physician (PCP): PATIENT INFORMATION Last Name: First Name: MI: Social Security #: DOB: Sex: M F Billing Address: City: ST Zip Code: Home Phone#:( ) Cell Phone#:( ) Work Phone#:( )
New Patient Information - Dr. Marc Edelstein
Marc A. Edelstein M.D., FACP, FACG Internal Medicine and Gastroenterology Gastroenterology, Hepatology, and Nutrition Susan P. Edelstein M.D., FAAP Pediatrics and Pediatric Gastroenterology Pediatric Gastroenterology,
Trinity Family Physicians
Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor
6677 W. Thunderbird F N. Hayden Rd. H-100 Glendale, Az Scottsdale, Az
Eye Physicians & Surgeons of Arizona 6677 W. Thunderbird F-101 10603 N. Hayden Rd. H-100 Glendale, Az. 85306 Scottsdale, Az. 85260 George R. Reiss, MD Shamil S. Patel, MD Vinay M. Dewan, MD Christina M.
5149 N. 9th Ave Suite G32 Pensacola, FL phone fax
Dear Patient: Enclosed you will find the following items: 1. Patient Data Sheet 2. Medical Records Release 3. Program Fee Information 4. Manual Registration 5. Photo and Interview Authorization Please
NEW & CURRENT PATIENTS
Patient Registration Update: NEW & CURRENT PATIENTS General Information: First Name: MI: Last Name: Prefix: Suffix: Address: Zip Code: City: State: Contact: Cell: Home: Work: Email: Insurance Information:
Morris Medical Center, P.A.
Thank you for choosing our practice to assist in your healthcare needs. We appreciate the confidence you and your personal physician have placed in us. Please read the following instructions and information
Spouse/Parent s Name Date of Birth / / Age Sex Relation to client Social Security # Phone Employed by Phone
Patient Information *ALL FIELDS NEEDED TO PROCESS CLAIM *Patient s Name * Address *Zip Code *Social Security Number / / Telephone (Home) (Work) (Cell) * Email address *Date of Birth / / Age Sex Marital
NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX
PATIENT INFORMATION NAME (LAST, FIRST, MIDDLE) SSN# BIRTH SEX ADDRESS CITY, STATE & ZIP CODE EMAIL: MAILING ADDRESS (IF DIFFERENT FROM ADDRESS) CITY, STATE & ZIP CODE HOME PHONE CELL PHONE OTHER PHONE
WELCOME TO SPORTS CONDITIONING AND REHABILITATION
WELCOME TO We are pleased you have chosen, (SCAR) for your physical therapy needs. We know there are many choices and we appreciate your confidence in us. You will find we provide unsurpassed individualized
WOMEN S PREMIER OBGYN REGISTRATION FORM
WOMEN S PREMIER OBGYN REGISTRATION FORM Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: q Miss q Ms. Marital status (circle one) Single / Married / Divorced / Sep / Widow Is
Who can we thank for referring you to our office?
SEP BADY, MD THOMMAN KURUVILLA, DPM EUGENE LIBBY, DO., F.A.C.O.S X. NICK LIU, DO MATTHEW HC OTTEN, DO TIMOTHY J. TRAINOR, MD MICHAEL A. TRAINOR, DO RANDALL E. YEE, DO Today s Date: Last Name: First Name:
DATE: PRIMARY LANGUAGE SPOKEN: PATIENT S LOCAL ADDRESS: (Street) (City) (Zip) PERMANENT ADDRESS (IF DIFFERENT):
DATE: PRIMARY LANGUAGE SPOKEN: PATIENT NAME: _ Nick Name: (Last) (First) (Middle) CHECK ONE: SEX: M F CHECK ONE: MARRIED SINGLE WIDOWED DIVORCED RACE: _ DATE OF BIRTH: SOCIAL SECURITY: PATIENT S LOCAL
Connecticut Asthma & Allergy Center LLC Registration Form
Name: Connecticut Asthma & Allergy Center LLC Registration Form Last First Middle Initial Date of Birth: / / Sex: Race: Ethnicity: Language: SS#: xxx-xx- Address: # Street Apt/PO Box Email: Town State
Patient Welcome Form!
Arthritis and Rheumatology Clinical Center of Northern Virginia, PLLC 8130 Boone Blvd suite 340 Vienna VA 22182 Mahsa Tehrani MD 703-734-2222 Mahnaz Momeni MD Patient Welcome Form Dear new patient, Welcome
Dear. If you have any questions, feel free to call our office. We look forward to seeing you. Sincerely,
Dear We would like to welcome you to our office and thank you for choosing Heritage Valley Medical Group Internal Medicine Associates. Our hours of operation are Monday through Thursday 8am-5pm, and Fridays
PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH
Name: Social Security# Address: City: State: Zip: Date of Birth: Phone: Cell: *Employer: Phone:
Gallatin Family Practice Center Subir Guha, M.D. * Noridia Mauras, D.O * 608 Commons Drive Suite A * Gallatin, TN 37066 Telephone (615)452-5901 Fax (615)451-2006 Name: Social Security# Address: City: State:
California Cardiovascular and Thoracic Surgeons
California Cardiovascular and Thoracic Surgeons 168 North Brent Street, Suite 508 Ventura, CA 93003 Telephone (805) 643-2375 Fax (805) 643-3511 Your assistance in completing the following information thoroughly
Please bring your insurance card, photo identification, and corresponding copayment with you when you check in for your appointment for all visits.
DIVISION 22 Silver Spring Office 10313 Georgia Avenue, Suite 202 Silver Spring, MD 20902 Rockville Office 15225 Shady Grove Road, Suite 306 Rockville, MD 20850 Phone:301-681-9101 Fax: 301-681-3525 Dear
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
Today s Date (mm/dd/yyyy):
115 Christopher Columbus Drive, Suite 301 Jersey City, New Jersey 07302 201-706-3808 http://www.drsmedicalassociates.com/ WELCOME TO DRS MEDICAL ASSOCIATES LLC. PLEASE COMPLETE THE FORM LEGIBLY AND ENTER
MasterCare Physical Therapy, Inc.
Patient Financial Responsibility To all of our Patients: We will, as a courtesy, file your insurance claims for you. Please be advised that it is solely your responsibility to know and to understand your
New Patient Registration Form
New Patient Registration Form Patient Information Name: (First) (Middle) (Last) SSN: of Birth / / Sex: Male Female Street Address (or PO Box): City: State: Zip: Marital Status: Single Married Divorced
Women s Care Center of Columbus, Inc.
Women s Care Center of Columbus, Inc. Dear New Patient, Welcome to the Women s Care Center of Columbus, Inc. We look forward to seeing you at your scheduled appointment. Please help us serve you better
Patient Name: Date of Birth: Last name, First Name. Address: Street, City, State, Zip. Cell Phone: Home Phone: Work Phone:
Center for Pediatric Adolescent Gynecology INSURANCE INFORMATION/PATIENT AGREEMENT Patient Name: Date of Birth: Last name, First Name Address: Street, City, State, Zip Email: Cell Phone: Home Phone: Work
70 Hatfield Lane Goshen, New York SSN: First Name: MI: Last Name: Employment: Employed Unemployed Retired Employer: Employer Address:
70 Hatfield Lane Goshen, New York 10924 SSN: First Name: MI: Last Name: Prefix (Ms., Mr.,) Sex: M F DOB: Marital Status: Single Married Divorced Widowed Spouse Name: Employment: Employed Unemployed Retired
Dental Insurance: Primary Carrier: Employee #: Insured s SSN #: Insured Birth date: Group #: Phone #: Insurance Company Address: City: State: Zip:
First Name: Middle: Last: Nickname: Date of Birth: Drivers License #: Male Female Single Married SSN #: Address: City: State: Zip: Home Phone: Work: Cell: Email address: Employer: Occupation: Spouse Name:
It is very important to bring the following to your first visit:
Dear New Patient: Welcome and thank you for choosing Capital Digestive Care! The enclosed packet contains important information for your upcoming appointment as well as our new patient registration forms.
Address: City/State: Zip: Billing Address: City/State: Zip: Home Phone: Cell Phone: Appointment reminder: Voice Text - Which #:
Office Use Only: Date of Intake: Appt date/time: Therapist: Insurance: Full Name: DOB: Sex: M F SSN: Page A-1 of 5 Billing Home Cell Work Email: Appointment reminder: Email Voice Text - Which #: Emergency
SUBURBAN UROLOGY ASSOCIATES Please Print
SUBURBAN UROLOGY ASSOCIATES Please Print PATIENT INFORMATION Patient Name: Last First M.I. Address: Street Birth date: Age: City State Zip SS# Sex Marital Status Home Ph. # Cell Ph. # Occupation: Work
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
Patient Registration WELCOME TO OUR OFFICE
Patient Registration WELCOME TO OUR OFFICE Date of Birth: Home Address: Apt / Unit: City: State: Zip: SSN: Telephone: Home: Cell: Work: Email: Marital Status: Name of Spouse / Partner: Preferred method
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION DATE Chart # PATIENT NAME AGE DATE OF BIRTH MALE FEMALE PREFFERED LANGUAGE RACE/ETHNICITY SINGLE, MARRIED, DIVORCED, SEPARATED,WIDOWED
ANNUAL EXAM WELCOME BACK!
ANNUAL EXAM WELCOME BACK Name: Date: An annual exam is preventative care consisting of a physical exam and possibly a Pap smear. If you have problems to discuss with the physician or nurse practitioner,
PATIENT S INFORMATION
PATIENT S INFORMATION Date: DOB: Social Security#: Patient Name: Last Name First Name Middle Name Address: E-mail Address:_ Phone Home: Cell: Work: Marital Status: Sex (Circle) M F Gender Identity (Circle)
Office Hours: Monday Friday from 8:30 am 5:00 pm, but are closed for major holidays.
Greetings from Barton Women s Health Health care is personal and we know you have many choices in your care. Thank you for choosing the practice of Barton Women s Health for your gynecological and/or obstetric
PATIENT S INFORMATION
PATIENT S INFORMATION Date: DOB: Social Security#: Patient Name: Last Name First Name Middle Name Address: E-mail Address:_ Phone Home: Cell: Work: Marital Status: Sex (Circle) M F Gender Identity (Circle)
New Patient Registration
New Patient Registration 900 Carillon Parkway, Suite 404 Saint Petersburg, Florida 33716 Ph: 727-572-1333 Fax: 727-572-1331 www.spencerdermatology.com Today s : / / Name: (First) (Middle) (Last) (Suffix)
Parkway Dental of Clinton Matthew K. Chow, D.D.S. 401 Clinton Parkway, Clinton, MS Patient Information:
Patient Information: Name: Date: Last, First MI (Preferred Name) Social Security #: Birth date: / / Gender: Family Status: Address: City/State/Zip: Phone (Home): (Cell): (Other): Employer Name: Work Phone:
Last Name First Name M.I. Age. Address City State Zip Code. Home Phone Cell Phone Work Phone Date of Birth
29 Barstow Road, Suite# 201, Great Neck, NY 11021 Tel. 516482-5400 Fax 516-482-5401 PATIENT REGISTRATION: Primary Care Dermatology Last Name First Name M.I. Age Address City State Zip Code Home Phone Cell
THEDA OAKS SURGERY CENTER
EMAIL: PATIENT INFORMATION PATIENT NAME (LAST NAME, FIRST NAME, M.I.) SEX: F ( ) M ( ) DATE OF BIRTH: SOCIAL SECURITY NUMBER: MARITAL STATUS : M ( ), S ( ), D ( ), W ( ) ADDRESS: CITY: MAIN PHONE NUMBER:
The St Mary Medical Center Financial Assistance program does not cover the cost from all physician offices.
1 St Mary Medical Center Dear Date St. Mary Medical Center is committed to providing high quality care to all in our community. We may be able to assist you with your medical bills if you are not able
Jeffrey L. Brooks, M.D. (707)
(707) 252-4955 Welcome to our practice! First, let us thank you for choosing Napa Vascular & Vein Center as your healthcare provider. We are dedicated to providing premier vascular assessment and treatment
Dear Patient, Now that you are 18 years old we need a signed copy from you on file. Attached is a copy of the HIPAA form.
Dear Patient, We have a signed consent form on file that one of your parents has signed giving us consent to treat you and, if covered, to bill the Insurance Company. Now that you are 18 years old we need
Baldwin Counseling Payment Agreement
Baldwin Counseling Payment Agreement Baldwin Counseling believes that a clear understanding of our financial policies is important for both client and therapist. We are fully committed to helping you accomplish
Welcome to our office
Welcome to our office I, the undersigned, realize that I am financially responsible for all services rendered to me by the Haben Practice for Voice & Laryngeal Laser Surgery, PLLC. For those insurances
TEXAS PEDIATRIC SPECIALTIES AND FAMILY SLEEP CENTER REGISTRATION FORM ADULT
Referring Physician: TEXAS PEDIATRIC SPECIALTIES AND FAMILY SLEEP CENTER REGISTRATION FORM ADULT Primary Care Physician: Patient s LEGAL Last name: First: Middle Initial: Patient Date of birth / / Marital
MacInnis Dermatology New Patient Registration Form
MacInnis Dermatology New Patient Registration Form Please print and answer all questions in full Date Patient Information (please complete using your name as listed on your insurance card) Patient First
Any recent Laboratory (blood work) results related to your visit with us. A list of your current medications with dosage and frequency taken
Dear New Patient: Welcome and thank you for choosing Capital Digestive Care! The enclosed packet contains important information for your upcoming appointment as well as our new patient registration forms.
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
New Wave Internal Medicine Clinic
Amber D. Colville, M.D. *Lydia Latour, M.D., * Ashleigh Teates NP-C Dear Patient, Thank you for your interest in becoming a new patient at New Wave Internal Medicine. Please fill out the enclosed paperwork
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
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM NAME: Age: DATE OF BIRTH: SSN: Sex: MARITAL STATUS: PRIMARY CARE PHYS: DRIVER S LICENSE # STATE IF CHILD, GUARDIAN S NAME: ADDRESS: City State Zip Code PHONE: Home Phone Cell Phone
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:
Pacific Coast Heart Center
Pacific Coast Heart Center Christine M. Theard M.D 33971 Selva Road Ste. 200 (949)495-0800 Office, Dana Point, CA 92629 (949)495-0805 Fax PacificCoastHeartCenter.com Dear patient: These are new patient
K A R A N J O HA R, M.D.
P: : REGISTRATION FORM - MAJOR MEDICAL Last Name: First and Middle Name: Social Security #: Birthdate: Age: Sex: F M Marital Status: M S D W Home Address: City: State: Zip: *Does the above address, match
Sabates Eye Centers P.O. Box Kansas City, MO (913)
Sabates Eye Centers P.O. Box 26425 Kansas City, MO 64196-6425 (913) 261-2020 Type of Visit: u Routine u Medical Contact Lens Wearer? u Yes u No PATIENT INFORMATION Name (Last, First, Middle Initial) Date
STUDENT STATUS: FULL TIME PART TIME NOT A STUDENT RESPONSIBLE PARTY: SELF GUARANTOR RELATIONSHIP
/ / Date Wellspring LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE WORK PHONE (EXT) PRIMARY CARE DOCTOR REFERRING PHYSICIAN / / SEX: F M OF BIRTH SOCIAL SECURITY # MARITAL
PATIENT INFORMATION. Name: Date of Birth: Age: Address: Social Security #: City: Sex: Marital Status: State: Zip: Language: GUARANTOR INFORMATION
PATIENT INFORMATION Name: Date of Birth: Age: Address: Social Security #: City: Sex: Marital Status: State: Zip: Language: Home Phone#: Race: Work Phone#: Ethnicity/Nationality: Cell Phone#: Employer:
Patient Information Form
Patient Information Form Thank you for choosing Bowers Family Medicine. Please completely fill out this form to ensure the fastest and best healthcare service. We may ask you to look over this information
Toll-free phone: MyWVHIPP ( ) Monday to Friday 8am to 5pm Fax: Website:
Dear Applicant, The West Virginia Health Insurance Premium Payment (HIPP) program reimburses the cost of health insurance coverage for eligible policyholders and their dependents that are current Medicaid
NEW PATIENT PACKET includes the following forms:
Thank you for choosing U.S. Dermatology Partners! We appreciate the opportunity to care for your health. REQUIRED ITEMS NEEDED FOR YOUR APPOINTMENT Completed New Patient Packet (see below) Valid Government
PATIENT REGISTRATION FORM
Today s Date / / PATIENT REGISTRATION FORM PATIENT INFORMATION Patient Name Last First Middle Is this your legal name? If not, what is your legal name? Birthdate Age Sex q YES q NO / / q M q F q T Street
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Last Name: Title: First Name: Middle Name: Nick Name: Marital Status: Address: City State Zip Code Home Phone: Work Phone: Cell Phone: SS#: DOB: Sex: Referring Dr: Referring
Patient Intake Form. How did you hear about us? (Please check one) Internet Doctor Referral Health Insurance. Friend/Patient Referral Drive- By Other
Patient Intake Form How did you hear about us? (Please check one) Internet Doctor Referral Health Insurance Friend/Patient Referral Drive- By Other If a Friend or Doctor referred you, please give us their
Cardiology Consultants of Atlanta, P.C N. Decatur Rd. Suite 395, Decatur GA, (404) phone (678) fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP
PATIENT INFORMATION PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) E-MAIL
Tree House Pediatrics, PLLC
Tree House Pediatrics, PLLC Office Policies Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policies allows for a good flow of communication
Ra m sd ell P ed iatrics, I nc.
Please Print Patient Information: Last Name First MI Address City State Zip - Home Phone Alt. Phone SSN Sex DOB / / Policyholder Information: Policyholder s Name Policyholder s Address Policyholder s DOB
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: