Mantonya Chiropractic Center LLC. New Patient Information Form (Please Print and complete all areas)
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1 DR NP X-ray # Mantonya Chiropractic Center LLC New Patient Information Form (Please Print and complete all areas) Name Today'sDate Legal First Middle Last Mailing Address City State Zip Birth Date Age SS# Sex: ( )Male ( )Female Marital Status: S M W D Partner Language: English Spanish Indian Japanese Chinese Korean French German Russian Italian Ukrainian Other Race: White/Caucasian American Indian/ Alaska Native Asian Native Hawaiian/Other Pacific Islander Black/ African American Decline to Answer Other Ethnicity: Hispanic or Latino Not Hispanic or Latino Decline to Answer Home Phone: Work Phone: Cell Phone: Cell Carrier Please check your contact preference: Hm Wk Cell Postal Mail hm: wk: Emergency Contact: Phone Number: Relationship Employed By Occupation Address City State Name of Partner/Spouse (or parent if minor) Spouse s (or parent if minor) Employer Person Responsible For Account Self Other: Their Address (if different than yours) Whom may we thank for referring you to us? Current Patient (their name) Family doctor Insurance Phone Book ( Windstream other ) Location Reputation Sign Other NP INTRO pg 1
2 Name Date We will make a copy of your insurance card/s. However, please complete the following information. Family Physician Name Do you have Health Insurance? ( )Yes ( ) No Primary Insurance Company Name ID# Grp# Do you have a secondary insurance coverage? Y N If yes, please complete the following: Secondary Insurance Company Name ID# Grp# Fees are payable the day of service unless arrangements are made otherwise. Today we are here to discover your goals and priorities as it relates to your health and wellness. Your answers will help us determine how we can best help you. Let s get started List Your THREE Major Reasons for Seeking our Care: Is this due to: Work injury ( )Yes ( )No Auto accident ( )Yes ( ) No Have you missed work due to this? ( )Yes ( ) No Have you ever attempted to help this in the past? ( )Yes ( ) No If yes, what happened and what prevented you from getting results? List Your THREE Most Recent Accidents or Injuries: 1. Year 2. Year 3. Year Have you ever had Chiropractic care in the past? ( )Yes ( ) No If yes, when & where? Female Patients: Are you pregnant? ( )Yes ( ) No NP INTRO pg 2
3 Health History Are you seeing anyone else for other problems or health conditions? Yes No Please list the problem/s, date problem/s began, and Provider/s treating you for the condition/s: Past Health History Have you ly Yes No If yes, include date & provider seen...been diagnosed with Diabetes? Type I or Type II been treated for hypertension? Do you smoke? Never Former Smoker Current/Every Day Smoker Current Some Day Smoker Medications What medications are you currently taking? Include vitamins, herbs, minerals List Date Started, Brand Name or Generic Name, Strength, Dosage, Frequency, Duration, Quantity, Refills Available, Prescribed by Please be as specific as possible. Check here if None. Name Dosage Frequency _ Do you have allergies? Food Environmental Medication None List Type of Allergy and Reaction Allergy Reaction NP INTRO pg 3 Welcome to our office! Rest assured we will do everything in our power to help you. If we can t help you, we will tell you and get you to the right place that can.
4 DR NP X-ray # Mantonya Chiropractic Center LLC New Patient Child Information Form (Please Print and complete all areas) Name Today'sDate Legal First Middle Last Mailing Address City State Zip Birth Date Age SS# Sex: ( )Male ( )Female Marital Status: S M W D Partner Language: English Spanish Indian Japanese Chinese Korean French German Russian Italian Ukrainian Other Race: White/Caucasian American Indian/ Alaska Native Asian Native Hawaiian/Other Pacific Islander Black/ African American Decline to Answer Other Ethnicity: Hispanic or Latino Not Hispanic or Latino Decline to Answer Home Phone: Work Phone: Cell Phone: Cell Carrier Please check your contact preference: Hm Wk Cell Postal Mail hm: wk: Emergency Contact: Phone Number: Relationship Employed By Occupation Address City State Name of Partner/Spouse (or parent if minor) Spouse s (or parent if minor) Employer Person Responsible For Account Self Other: Their Address (if different than yours) Whom may we thank for referring you to us? Current Patient (their name) Family doctor Insurance Phone Book ( Windstream other ) Location Reputation Other NP INTRO pg 1
5 Name Date We will make a copy of your insurance card/s. However, please complete the following information. Family Physician Name Do you have Health Insurance? ( )Yes ( ) No Primary Insurance Company Name ID# Grp# Do you have a secondary insurance coverage? Y N If yes, please complete the following: Secondary Insurance Company Name ID# Grp# Fees are payable the day of service unless arrangements are made otherwise. Today we are here to discover your goals and priorities as it relates to your health and wellness. Your answers will help us determine how we can best help you. Let s get started List Your THREE Major Reasons for Seeking our Care: Is this due to: Work injury ( )Yes ( )No Auto accident ( )Yes ( ) No Have you missed work due to this? ( )Yes ( ) No Have you ever attempted to help this in the past? ( )Yes ( ) No If yes, what happened and what prevented you from getting results? List Your THREE Most Recent Accidents or Injuries: 1. Year 2. Year 3. Year Have you ever had Chiropractic care in the past? ( )Yes ( ) No If yes, when & where? Female Patients: Are you pregnant? ( )Yes ( ) No NP INTRO pg 2
6 Health History Are you seeing anyone else for other problems or health conditions? Yes No Please list the problem/s, date problem/s began, and Provider/s treating you for the condition/s: Past Health History Have you ly Yes No If yes, include date & provider seen...been diagnosed with Diabetes? Type I or Type II been treated for hypertension? Do you smoke? Never Former Smoker Current/Every Day Smoker Current Some Day Smoker Medications What medications are you currently taking? Include vitamins, herbs, minerals List Date Started, Brand Name or Generic Name, Strength, Dosage, Frequency, Duration, Quantity, Refills Available, Prescribed by Please be as specific as possible. Check here if None. Name Dosage Frequency _ Do you have allergies? Food Environmental Medication None List Type of Allergy and Reaction Allergy Reaction NP INTRO pg 3 Welcome to our office! Rest assured we will do everything in our power to help you. If we can t help you, we will tell you and get you to the right place that can.
7 Mantonya Chiropractic Centers LLC Pediatric Case History Child s Name Date Welcome to Mantonya Chiropractic Center, A)Child s Main Complaint(s): (B) Child s Birth: (E) Any prescription or Colic Normal Vaginal non-prescription Ear Infections Complicated Birth medication your child Colds C-Section is taking: Headaches Forceps Back Pain Suction Seizures Arm Pain (C) Has Your Child: Leg Pain Played Sports (F) Their Pediatrician: Vomiting Been Knocked Unconscious Attention Deficit Been in an Auto Accident Fatigue Fallen Bed Wetting Broken Any Bones (G) Has your child seen a Asthma Chiropractor before: Diarrhea YES NO Constipation (D)Recent Injuries: If So: Allergies Who? Nose Bleeds When? Lazy Eye Other: Parental/Guardian Consent for Care I, (parent/legal guardian) give my permission to Mantonya Chiropractic Center LLC and the Doctors within to perform the necessary diagnostic tests and to render the recommended treatments, thereafter to. A photocopy of this consent form will be as effective and valid as the original. Signature Date Parent/Legal Guardian Signature Date Witness Pediatric Consent pg4
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:
HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN (317)
HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN 46037 (317)-284-8888 Patient Name: Date of Birth: / / First MI Last SS#: Address: City: State: Zip Code: Cell Phone: ( ) - Home Phone:
List the names of any relatives that have or have had a similar problem. CMS requires providers to report both race and ethnicity
APPLICATION FOR TREATMENT Date Name: Age: Date of Birth: Address: City State ZIP Phone: Home Work Cell Email: Preferred method for appointment reminders: [] Email []Phone [] Mail Marital Status: [] Married
PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
PATIENT REGISTRATION
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Other, please explain
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PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:
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PATIENT PROFILE PATIENT INFORMATION: Name: Date of Birth: Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed Address: City: Zip: Home#: Message#: Name of Primary Physician,
Patient Registration Form
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Your Community Health Center If you need help filling out this form, please let us know. PATIENT REGISTRATION FORM (Please Print) Today s Date: YCHC Medical Provider: YCHC Dental Provider: PATIENT INFORMATION
PATIENT INFORMATION ADDRESS STREET CITY STATE ZIP HOME ( ) WORK ( ) EXT. CELL ( ) PERSON RESPONSIBLE FOR ACCOUNT: OCCUPATION: EMPLOYER: CDL#:
PATIENT INFORMATION DATE FIRST NAME LAST NAME ADDRESS STREET CITY STATE ZIP HOME ( ) WORK ( ) EXT. CELL ( ) BIRTH DATE / / AGE SS# - - MARITAL STATUS: S M. D. W PERSON RESPONSIBLE FOR ACCOUNT: OCCUPATION:
NARRA DERMATOLOGY AND AESTHETICS (425) Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields)
NARRA DERMATOLOGY AND AESTHETICS (425) 677-8867 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name Address Last First Middle Street & Apt
Orthopedic Intake. Patient Name: Date of Birth: Age: Sex: Male or Female. What are we seeing you for? Pneumonia vaccine?
Orthopedic Intake Date: Patient Name: Date of Birth: Age: Sex: Male or Female What are we seeing you for? Have you had Flu vaccine? q Yes q No Date Pneumonia vaccine? q Yes q No Date List of Past Surgeries:
ELYSE S. RAFAL, F.A.A.D.
ELYSE S. RAFAL, F.A.A.D. Welcome to our practice. Thank you for placing your trust in us. We look forward to serving you with quality and compassionate care. Patient Information Today s : First Name: M.I.
Pediatric Intake Form
Child s Legal Name: Today s Date: / / Address: City: ST: Zip: Home Phone: Parent s Cell Phone: Date of Birth: / / Age: Gender: M F Social Security #: Mother s Name: Father s Name: Sibling s Name(s) and
AUTHORIZATION FOR TREATMENT
Thank you for choosing ARIZONA MANUAL THERAPY CENTERS. Please read each section below carefully, sign and date, and return to the front office personnel. If you have any questions or concerns, please ask
Chiropractic Case History / Patient Information
Chiropractic Case History / Patient Information Date: Name: Social Security #: Home Phone:( ) Address: City: State: Zip: E mail address: Cell Phone:( ) Age: Birth Date: / / Marital Status: M S W D Occupation:
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
Minor Registration Forms Please Print Legibly. Demographics. *Patient Last Name: *First Name: Middle Initial:
*Indicates Required Fields Minor Registration Forms Please Print Legibly Demographics *Patient Last Name: *First Name: Middle Initial: *Date of Birth: / / *Gender: Male Female *Prefix: Mr. Miss Ms. Mrs.
Patient Health Information Consent Form
Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any
APPLETON PLASTIC SURGERY CENTER, S. C. (920)
APPLETON PLASTIC SURGERY CENTER, S. C. (920)738-7200 Please print legibly and fill in or correct all fields. Patient Name Parent/Legal Guardian Name Address Last First Middle Last First Middle Street &
Kipp M. Robins, MD * Aaron Paxman, PA * Family Audiology TODAY S DATE PATIENT S NAME: BIRTHDATE
Kipp M. Robins, MD * Aaron Paxman, PA * Family Audiology PATIENT S NAME: TODAY S DATE BIRTHDATE WAS THERE A DOCTOR WHO REFERRED YOU? No Yes If yes, who Who is your Family or Primary care doctor? WHAT are
Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ
Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ 85260 480-443-2584 www.wellnessdoc.com Date Home Phone Work Phone Cell # Patient e-mail: Last Name First Name Street Address City
City: State: Zip: Home Cell Work Alternate Phone: Address: Home Cell Work Sex: Male Female Marital Status: Single Married Other:
Denton Sanger Aubrey Patient Information Patient Registration Information Name: (First) (MI) (Last) Social Security #: Date of Birth: Address: Phone: City: State: Zip: Home Cell Work Alternate Phone: Email
Bay Area Podiatry Associates, PA
Patient Demographic Information Patient s Name: Date: SS#: DOB: Age: Sex: F M Home Address: Marital Status: Single Married Widow Divorced Separated City: State: Zip: Home Phone: Cell Phone: Work Phone:
Austin Kinesiology And Chiropractic
PATIENT INFORMATION Patient Name: Date of Birth: Sex: M F Age: Soc. Sec. #: - - Photo ID #: State: Address: City, State, Zip: Mobile Phone: Home Phone: Work Phone: Email address: We will not share your
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
Referring Physician: Primary Care Physician: Eye Care Physician: Specialty Care Physician(s):
Eye Physicians and Surgeons, P.A. Please Print Patient s Legal Name: Street Address: City State Date ofbirth: / / Marital Status (circle one) Zip. S/M/W Sex: M F E-mail: Patient s Employer: Spouse s Name:
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
Patient Registration
Patient Registration Please check Primary Home Work Cell phone Gender SSN E-mail Address Driver s License M F Marital Status Preferred Contact Ethnicity Race Married Single Divorced Separated Widowed Life
Chiropractic Case History/Patient Information
1 Dr. Gregory T. Kaumeyer, D.C., C.C.S.P., C.M.E. Chiropractic Case History/Patient Information 100 Ridgeway St., Suite 8 Hot Springs, Arkansas 71901 P 501-463-9477 F 501-463-9478 Date: Patient # Doctor: