Patient Information. Primary Care Physician: Last Name: First Name: MI: Address: City/ST/Zip code: Home Phone :( ) Cell Phone: ( ) Leave Message
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1 Patient Information Last Name: First Name: MI: Address: City/ST/Zip code: Home Phone :( ) Leave Message Cell Phone: ( ) Leave Message Work Phone: ( ) ext: Date of Birth (mm/dd/yyyy): / / Sex: Male Ο Female Ο Marital Status: Married: Divorced: Single: Widowed: Social Security: (REQUIRED) Primary Insurance: Policyholder: DOB: / / SSN: Group ID #: Individual ID #: Secondary Insurance: Policyholder: Name: DOB: / / SSN: Group ID #: Individual ID #: Primary Care Physician: Driver s License #: State Race: American Indian or Alaska Native Ο Asian Ο Native Hawaiian Ο Hispanic Ο African American Ο White O Other Race Ο Ethnicity: Hispanic Ο Non Hispanic Ο Pharmacy where you want your prescriptions sent: Pharmacy Name: Address:
2 Male Patient Questionnaire & History Social: ( ) I am sexually active. ( ) I want to be sexually active. ( ) I have completed my family. ( ) I have used steroids in the past for athletic purposes. Habits: ( ) I smoke cigarettes or cigars a day. ( ) I drink alcoholic beverages per week. ( ) I drink more than 10 alcoholic beverages a week. ( ) I use caffeine a day. Medical History Any known drug allergies: Have you ever had any issues with anesthesia? ( ) Yes ( ) No If yes please explain: Medications Currently Taking: Current Hormone Replacement Therapy: Past Hormone Replacement Therapy: Nutritional/Vitamin Supplements: Surgeries, list all and when: Medical Illnesses: ( ) High blood pressure. ( ) High cholesterol. ( ) Heart Disease. ( ) Stroke and/or heart attack. ( ) Blood clot and/or a pulmonary emboli. ( ) Hemochromatosis. ( ) Depression/anxiety. ( ) Psychiatric Disorder. ( ) Testicular or prostate cancer. ( ) Elevated PSA. ( ) Prostate enlargement. ( ) Trouble passing urine or take Flomax or Avodart. ( ) Chronic liver disease (hepatitis, fatty liver, cirrhosis). ( ) Diabetes. ( ) Thyroid disease. ( ) Arthritis. I understand that if I begin testosterone replacement with any testosterone treatment, including testosterone pellets, that I will produce less testosterone from my testicles and if I stop replacement, I may experience a temporary decrease in my testosterone production. Testosterone Pellets should be completely out of your system in 12 months. By beginning treatment, I accept all the risks of therapy stated herein and future risks that might be reported. I understand that higher than normal physiologic levels may be reached to create the necessary hormonal balance. Print Name Signature Today s Date
3 Medical Release Form I, hereby authorize the physician and staff of CWC permission to release information concerning my health and well-being to the following: Ο Leave message on answering machine - Phone Number: Ο I DECLINE to authorize the release of information concerning my health and wellbeing. The following information may be given to the above individuals: (please check all you agree to): Ο Any other information (No limitation) includes all communication. Ο Appointment Time Ο Test/Lab Results Ο Procedures Ο Medications The following items may be picked up on my behalf by the above individuals: (please check all you agree to): Ο Written Prescriptions Ο Copy of Medical Recordsl Ο Radiology Films Ο Laboratory Results Ο Any other information regarding my health I understand I may revoke this consent at any time by giving written notice to the person or organization making the disclosure. I understand that this organization originates and maintains health records describing my health history, symptoms, diagnoses, examinations, past/current/future treatments and test results as well as financial information pertaining to my account. I acknowledge that I have been provided with Full Disclosure of their Notice of Privacy Practices and I consent to the use and disclosure of my own or persons form whom I am responsible (i.e. minors) Financial and Health Information for any reason that Choctaw Womens Clinic may require to carry out Health care operations to or for me and/or for persons whom I am responsible. Patient Signature: Date: (Parent/Guardian Signature if patient is a minor.).) Witness Signature: Date: If this form is not filled out and/or signed by the patient or legal guardian, no information can be given regarding your medical care to any individual including spouse and/or family members. This includes copies of medical records, radiology films or prescriptions on your behalf. If you have any questions regarding this authorization, please ask the receptionist for additional information.
4 Laboratory We ask that each patient know his/her insurance benefits, including your lab benefits, prior to your scheduled appointment time. You will need to know how much your individual lab policy covers and which lab your insurance prefers you go to (DLO or Lab Corp). You have the option to send your lab through your insurance or you can choose to do self pay through us. If you choose to send through your insurance you will be responsible for any co insurance or deductible that applies. You will not receive a bill for lab work from Choctaw Women`s Clinic for your lab work, it will come from the lab itself. If you choose self pay, you pay us at date of service and you will not receive a bill from the labs. Circle one: Insurance or Self pay Patient Signature Date Choctaw Women s Clinic No Show and/or Cancellation Policy Failure to CANCEL within a 24 hour time prior to your appointment time will result in a $35 fee. Failure to NOT SHOW for an appointment will result in a $35 no show fee. Choctaw Women s Clinic No Show and/or Cancellation Policy for Consultation or a Pellet Procedure Failure to CANCEL a consultation or pellet procedure within a 24 hour time prior to your appointment time will result in a $50 fee. Failure to NOT SHOW for a consultation or pellet procedure will result in a $50 no show fee. I understand the above cancellation and no show policy. Signature Date
5 Male Symptom Checklist Symptoms (please check mark) Decline In General Well Being Fatigue Joint Pain & Muscle Aches Excessive Sweating Sleep Problems Increased Need For Sleep Irritability Nervousness or Anxiety Depressed Mood Exhaustion & Lacking Vitality Declining Mental Focus & Concentration Feeling You Have Passed Your Peak Feeling Burned Out Decreased Muscle Strength Weight Gain, Belly Fat or Inability to Lose Weight Breast Development Shrinking Testicles Rapid Hair Loss Decrease in Beard Growth New Migraine Headaches Decreased Sexual Desire or Libido Decreased Morning Erections Decreased Ability to Perform Sexually Infrequent or Absent Ejaculations No Results From E.D. Medications Never Mild Moderate Severe I Smoke Cigarettes or Cigars Per Day. I Drink Alcoholic Beverages Per Week. Current Hormone Replacement Therapy: Past Hormone Replacement Therapy: Nutritional Supplements/Vitamins: Have You Ever Had Any Issues With Anesthesia (Y/N): Explain: History of Prostate Cancer (Y/N): I Am Sexually Active (Y/N) : I Have Completed My Family (Y/N):
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
Female Patient Questionnaire & History
Female Patient Questionnaire & History Name: Today s Date: (Last) (First) (Middle) Date of Birth: Age: Occupation: Home Address: City: State: Zip: E-Mail Address: May we contact you via E-Mail? ( ) YES
Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N
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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.
PATIENT INFORMATION. Patient Name: Last First Middle Nickname. DOB: Sex: SSN: Marital Status: Drivers Lic #:
PATIENT INFORMATION Preferred Provider: Dr. Preferred Pharmacy: Patient Name: Last First Middle Nickname DOB: Sex: SSN: Marital Status: Drivers Lic #: Ethnicity (circle one): African American American
PATIENT INFORMATION FORM - DIABETES
PATIENT INFORMATION FORM - DIABETES PATIENT NAME: DATE OF BIRTH / / (mm/dd/yr) SOCIAL SECURITY NO - - ADDRESS HOME PHONE: ( ) CELL PHONE: ( ) WORK PHONE: ( ) EMPLOYER EMAIL: MARITAL STATUS S M W D SEP
Cheyenne Foot & Ankle
Cheyenne Foot & Ankle Patient Registration and Health History I Patient Information Date: Patient Address City State Zip Phone Cell Work e-mail Address Date of Birth Age Sex M or F Patient SSN Whom may
NORTHSIDE PRIMARY CARE
NORTHSIDE PRIMARY CARE Dr AAZRUM I. SYED, M.D. 11820 Northfall Lane Suite 1103 ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES **You may refuse to sign this acknowledgment** I, have received
Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male
Patient Information Patient Name: Last First Middle Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: of Birth: / / Social Security #: - - Marital Status:
Patient Information. Medical Insurance/Policy Holder
Patient Information (Print legibly in Blue or Black Ink ONLY) Last Name: First Name: M.I. Address: City: State: Zip: SSN: DOB: Sex: M/F Shoe size: Height: Weight: Race: Home: Work: Cell: Employer: Emergency
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014 Patient name: Account# Ear, Nose and Throat Associates, PC, believes that in the interest of good health care practices,
You will need to bring all of your insurance cards and a photo ID. If you have seen another doctor in the past, please bring in your records.
Welcome to AMELI DADOURIAN HEART CENTER Enclosed you will find a patient profile packet. Please complete these forms and bring them with you to your appointment. Please do not e-mail your forms to us.
If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:
AMELIA A. PARÉ, M.D. PATIENT REGISTRATION Date of visit: PATIENT INFORMATION (PLEASE PRINT) Name: Date of Birth: Age: Male Female Race Social Security #: Marital Status: Single Married Divorced Widowed
WEST COAST VASCULAR PATIENT INFORMATION LAST FIRST MI BIRTHDATE SS# PHONE ADDRESS CITY ST ZIP EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT
C. Shawn Skillern, M.D. Li Sheng Kong, M.D. Sydney S. Guo, M.D. Edward N. Li, M.D. Kevin M. Casey, M.D. Sara J. Runge, M.D. WEST COAST VASCULAR 100 North Brent Street, Suite 201 I Ventura, CA 93003 2100
Please be aware that this office does not do pain management and will not prescribe narcotics to new patients, nor on an ongoing basis.
Patient Information Sheet Last Name: First Name: Middle Initial: Patient Is: Policy Holder Responsible Party RESPONSIBLE PARTY Last Name: First Name: Middle Initial: Address: City, State, Zip: Home Phone:
Personal Medical History Form Please Print
Personal Medical History Form Please Print PATIENT S LEGAL NAME: REFERRED BY: REASON FOR VISIT: TODAY S DATE: BIRTH DATE: PLEASE ANSWER ALL OF THE QUESTIONS AS ACCURATELY AS POSSIBLE. IF YOU DO NOT UNDERSTAND
TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A.
TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A. James T. Siminski, M.D., FCCP Donald L. Washington Jr, M.D. 1604 Hospital Parkway, Suite 403 Bedford, TX 76022-6932 (817) 354-9545 (817) 354-8157 Fax Thank
**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
Anthony Sparano, M.D.
Anthony Sparano, M.D. Facial Plastic Surgeon Sparano Face & Nasal Institute NJ Institute for Robotic Hair Surgery Skin Sense Spa Patient : DOB: Date: Home Phone: ( ) Mobile Phone: ( ) E mail Address: Please
BenchMark Rehab Partners Welcome to
BenchMark Rehab Partners Welcome to At BenchMark Rehab Partners we believe communication is essential to achieving the best possible patient outcomes. Understanding your needs and expectations is essential
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