Uri M. Ben-Zur, M.D., F.A.C.C. The Cardiovascular Institute Heart Rhythm and Interventional Cardiology Center
|
|
|
- Annabel Harrell
- 5 years ago
- Views:
Transcription
1 Uri M. Ben-Zur, M.D., F.A.C.C. The Cardiovascular Institute Heart Rhythm and Interventional Cardiology Center Dear Valued Patient, Welcome to the family! At the Cardiovascular Institute all of our patients are like family. We strive to provide the best cardiovascular care available in a comfortable environment. I personally have many years of experience treating complicated cardiovascular cases and am confident that your experience in our office will be an unforgettable one. We are a unique practice with our compassionate care and our seamless integration of medical technology. One important feature of our innovative approach to managing your health is the use of an electronic medical records system, which allows us to have all of your medical records in one secure database. This gives us the ability to send your records to any medical professional who needs them, rapidly. In the event of a medical emergency where seconds and minutes make the difference, this is extremely important. Thank you for choosing our practice. My team and I look forward to caring for you and helping you to preserve your health. Again, welcome to the family. Uri Ben-Zur, M.D., F.A.C.C. Copyright THE CARDIOVASCULAR INSTITUTE. All rights reserved. Page 1 of 7
2 Uri M. Ben-Zur, M.D., F.A.C.C. The Cardiovascular Institute Heart Rhythm and Interventional Cardiology Center Patient Information Sheet First Name: Middle Initial: Last Name: Date of Birth: Social Security Number: Street Address: Marital Status: Gender: M State & Drivers License#: F City: for Portal Access: State: Zip: Home Phone: Cell Phone: Work Phone: Emergency Contact: Relationship: Emergency Contact Phone Number(s): Occupation: Employer: Referring Physician: Referring Physician's Phone/Address: Dr. Uri M. Ben-Zur is a cardiologist and does not practice general internal medicine. If you do not already have an internist, you are strongly advised to seek the care of one so that routine examinations such as breast, prostate, colonoscopy procedures, as well as other internal medicine issues may be addressed. Please note that this agreement remains active as long as you are under Dr. Uri M. Ben-Zur's care. Patient's Signature: Date: Print Patient's Name: Witness' Signature: Date: Copyright THE CARDIOVASCULAR INSTITUTE. All rights reserved. Page 2 of 7
3 Uri M. Ben-Zur, M.D., F.A.C.C. The Cardiovascular Institute Heart Rhythm and Interventional Cardiology Center Today's Date: Patient's Last Name, First Name: Patient's Date of Birth: Referring MD: Previous Cardiologist: Primary Complaint(s): Previous Cardiac Procedures: Prior/Present Medical Conditions: Previous Surgeries: Dates: Copyright THE CARDIOVASCULAR INSTITUTE. All rights reserved. Page 3 of 7
4 Allergies/Reactions to Medication: Current Medications: Mg Dosage: Frequency: Start Date: Blood Relative Age and Medical Conditions If Deceased, Age and Cause of Death Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children: Siblings: Copyright THE CARDIOVASCULAR INSTITUTE. All rights reserved. Page 4 of 7
5 Please check any conditions that you have experienced in the last 12 months. Cardiac: Chest Pain Palpitations Unusual Sweating Stroke Vascular: Leg Pain Swelling Phlebitis Calf Pain Constitutional: Weight Gain Weight Loss Fever HEENT: Vision Changes Hearing Loss Respiratory: Snoring Coughing Up Blood Shortness of Breath Asthma TB Inhalers Valley Fever Pneumonia Pleurisy Gastrointestinal: Nausea Reflux Bloody Stools Diarrhea Constipation Gall Bladder Trouble Frequent Abdominal Pain Change in Bowel Habits Indigestion or Heartburn Peptic Ulcers Genitourinary: Blood in Urine Night-time Urination >2 Urinary Tract Infection Leaking Urine Painful Urination Psychiatric: Depression Hallucinations Anxiety OCD Reproductive (Men): Reproductive (Women): Venereal Disease Erectile Dysfunction Venereal Disease Infertility Oral Contraceptives Irregular Menstruation Kidney Stones Painful Menstruation Irregular Pap Smear Menopause Pregnancies Total: Miscarriages Total: Terminations Total: Endocrine: Goiter Tremor Enlarged Glands Thyroid Disease Dermatological: Rash Skin Sores Hives Musculoskeletal: Joint Pain Muscle Aches Scoliosis Broken Bones Arthritis Copyright THE CARDIOVASCULAR INSTITUTE. All rights reserved. Page 5 of 7
6 Please check the appropriate response and provide additional information when necessary. Caffeine: Do you drink Yes No Drinks per day: caffeinated beverages? Alcohol: Do you drink alcohol? Yes No Drinks per day: Tobacco: Do you smoke tobacco? Yes No If yes, Years smoked: Packs/day: Drugs: Exercise: Diet: Stress Level: Do you use drugs recreationally? How would you describe your level of activity? How would you describe your diet? How would you describe your stress level? Quit Year Quit Cigarettes? Pipes? Cigars? Yes No List drugs used: Sedentary Occasionally Active Regularly Active Very Active Varies Low Fat Low Salt Vegetarian Diabetic Gluten free Fast Food Low Moderate High Very High How many blocks can you walk? How many glasses of water do you drink daily? Copyright THE CARDIOVASCULAR INSTITUTE. All rights reserved. Page 6 of 7
7 Uri M. Ben-Zur, M.D., F.A.C.C. The Cardiovascular Institute Heart Rhythm and Interventional Cardiology Center Billing Policies To Our Valued Patient: The following details our policies regarding insurance and billing procedures. Please take a few moments to review and sign below. Payments can be made online via If you have any questions, please do not hesitate to contact us and ask. Co-Payments: All co-payments are due at the time of service. The amount of your co-payment is noted on your insurance identification card. HMO Patients: We do not coordinate payment with HMOs. Patients with HMO coverage are responsible for complete payment of our bill. Private or PPO Insurance Patients: We will bill your primary and secondary insurance providers; please be aware that we do not coordinate with tertiary insurance providers. The patient is responsible for any unpaid balances. Medicare Patients: We do accept Medicare assignment. We will bill Medicare directly, as well as any secondary insurance. We do not coordinate with tertiary insurance providers. The patient is responsible for any unpaid balances. All Patients: Please be aware that insurance companies offer myriad coverages, and it is your responsibility to understand what your plan provides for. This may change over time, so it is always useful to check with your insurance company on a regular basis. The patient is responsible for all unpaid balances. If you need assistance regarding your insurance or bill payment, please contact us immediately. My signature below indicates my authorization that my insurance benefits are to be paid directly to Uri Ben-Zur, M.D., F.A.C.C. I am financially responsible for any charges and/or services not covered by my insurance company. I also authorize the physician and his staff to release any information required. I have received the notices of privacy and disclosure and have been provided opportunity to review them. Please note that this agreement remains active as long as you are under Dr. Uri M. Ben-Zur's care. Patient's Signature: Date: Print Patient's Name: Witness' Signature: Date: Copyright THE CARDIOVASCULAR INSTITUTE. All rights reserved. Page 7 of 7
8 PHYSICIAN-PATIENT ARBITRATION AGREEMENT Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided by a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term patient herein shall mean the mother and the mother s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure and and Civil Code and Any party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure , however, depositions may be taken without prior approval of the neutral arbitrator. Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration. Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition. Article 6: Retroactive Effect: If the signing party intends this agreement to cover all services rendered before the date of the signing of this agreement (including, but not limited to, prior consultations or treatment), the signing party must initial to the right of this clause. Signing Party Initials: If any provision of this arbitration agreement is held invalid of unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT DRAFT ONLY ORIGINAL TO BE SIGNED IN THE OFFICE A signed copy of this document is to be given to Patient. Original is to be filed in Patient s medical records.
Welcome to Precision Rehabilitation
Welcome to Precision Rehabilitation We are happy you have chosen Precision Rehabilitation for your therapy services. Customer Service is our utmost priority. In order to provide quality rehabilitation
Pasadena CA office fax
office@m PATIENT INFORMATION (please print) Gender: DOB: SSN: Driver s License Number: Expiration State: Home Phone: Work Phone: Mobile Phone: Email: Address: City: State: Zip Code: Ethnicity: (please
Victory Health, PLLC 4000 Shipyard Blvd, Suite 120 Wilmington, NC ARBITRATION AGREEMENT
Victory Health, PLLC 4000 Shipyard Blvd, Suite 120 Wilmington, NC 28412 ARBITRATION AGREEMENT Article 1: Agreement to Arbitrate: The undersigned hereby agree that any dispute arising out of the treatment
NEW PATIENT CONSULTATION. List of your current medications and allergies. Insurance Cards and Vision Insurance Information
NEW PATIENT CONSULTATION Please bring all the following to your appointment along with the forms completed and signed. List of your current medications and allergies Insurance Cards and Vision Insurance
Patient Information Last Name First Name Middle Initial
Patient Information Last Name First Name Middle Initial Street Address Apt# City State Zip Code Social Security # Home Phone Cell Phone Email D.O.B Sex(M/F) Occupation Relation to Insured Self Spouse Child
Date of Birth: Age: Social Security #: Address: City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div
Your Name: Email Address: Date of Birth: Age: Social Security #: Address: _ City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div Spouse s Name: Emergency Contact: Telephone
VASCULAR HEART & LUNG ASSOCIATES
PATIENT INFORMATION Last Name: First Name: M.I: Address: City: State: ZIP: Telephone (Cell): (Home): (Circle preferred contact method). Email: Date of Birth (MM/DD/YEAR): / / Age: Sex: SS# Ethnicity [circle]:
KNIGHTSBRIDGE INTERNAL MEDICINE & CARDIOLOGY, INC. New and Current Patient Information Sheet
KNIGHTSBRIDGE INTERNAL MEDICINE & CARDIOLOGY, INC. New and Current Patient Information Sheet PATIENT INFORMATION Name: (First)(MI) (Last)_Date: _ Date of Birth Age Sex: M F Marital Status: S M W D Race:
Chong S Kim, MD ENT and Facial Plastic Surgeon
Chong S Kim, MD ENT and Facial Plastic Surgeon 100 Commons Way, Suite 701 300 Perrine Rd., Suite 301 Holmdel, NJ 07733 Old Bridge, N.J 08857 Phone: 732-796-0182 Phone: 732-727-1355 Fax: 732-796-0186 Fax:
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
PATIENT REGISTRATION FORM
ph. 912.303.0891 x: 912.303.0893 UROGYNsavannah.com 5356 Reynolds Street Suite 301 Savannah, GA 31405 PATIENT REGISTRATION FORM Date Patient Name DOB SSN (Last, First, Middle Initial) Address: (City, Street,
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
ATIGA FAMILY PRACTICE Jefferson Ave Ste. 204 Temecula Ca, Patient Registration
ATIGA FAMILY PRACTICE 27699 Jefferson Ave Ste. 204 Temecula Ca, 92592 Patient Registration Patient Information Name: Date of Birth: Social Security Number: Gender Address: Preferred language: Do you need
Ayurveda Wellness Counseling
Patty Hlava, Ph.D., AWC, C.MI., RYT phlava@healthwisestudio.com Ayurveda Wellness Counseling Name: DOB: Date: Home Address: City: Phone: Email: State, Zip: Cell Phone: Occupation: Age: Personal Physician:
TEXT YES VOICE YES PHONE NUMBER PHONE NUMBER
Dr. Gann's Diet of Hope Name: D.O.B To allow patients to easily access their statements and communicate with Providers we are glad to provide you access to our Patient Portal. Please provide your email
Jandali Plastic Surgery
Jandali Plastic Surgery PATIENT INFORMATION FORM : FirstMiddle Last Address: City State Zip Code Home Phone #( ) - Work #( ) - Cell #( ) - Emergency # ( ) - Emergency Contact Social Security Number - -
ORTHOSYNTHESIS FAISAL MIRZA, M.D.
ORTHOSYNTHESIS FAISAL MIRZA, M.D. ADULT PATIENT INFORMATION FORM Today s Date: Referred By: (Is referral a former patient? Yes/No) Patient Name: Social Security #: Date of Birth: Age: Gender M/F: Home
Name: Date of Birth: Sex: Office: Date:
Patient Information Name: Date of Birth: Sex: Office: Date: Address: City: State: Zip: Social Security Number: Home Phone: Cell Phone: Email: May we leave a message? Email? Martial Status Emergency Contact
Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?
Thank You, Colorado Kidney Care Team. Review of systems
1 Welcome to Colorado Kidney Care! This packet contains important information to ensure a productive and thorough visit. Please take the time to complete these forms in as much detail as possible. Please
WELCOME TO OUR PRACTICE! We look forward to seeing you very soon.
WELCOME TO OUR PRACTICE! We are glad to welcome you to Park Avenue Oculoplastic Surgeons (PAOS) and Park Avenue Surgery Center (PASC). Enclosed are some materials which will acquaint you with our facilities,
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX Phone: Fax: Address: City: ST: ZIP:
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX 75082 972-649-5937 Fax: 972-807-0385 Patients General Information Last Name: First Name: Patient s SSN: of Birth MM/DD/YYYY: / / Age: Sex: M/F
PATIENT REGISTRATION FORM
24910 Las Brisas Rd., Suite 115 Murrieta, CA 92562 (951) 698-7366 Date: PATIENT REGISTRATION FORM Demographics Patient Name: Birthdate: Last First M.I. Address: Marital Status: : Gender: Home Phone: SSN:
Name Date of Birth / / First M.I. Last. Address City State Zip. Home Phone Cell Phone Work Phone. Address
3055 SOUTHWESTERN BLVD. 3500 SHERIDAN DR. ORCHARD PARK, NY 14227 AMHERST, NY 14226 (716) 675 2500 (716) 204 4263 PATIENT INFORMATION (Please Print) Today s Date: / / Name Date of Birth / / First M.I. Last
Name (Last, First, MI): Date of Birth: / /
Name (Last, First, MI): Address: Age: City: State: Zip: Sex: Male / Female Phone #: (Home): (Cell): (Work): Personal Email: Social Security #: Race: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Other
RESPONSIBLE PARTY DEMOGRAPHIC INFORMATION
BRYAN LEATHERMAN, M.D. PATIENT DEMOGRAP H I C INFORMATION Last Name First Name Middle Preferred Name Maiden Prefix Suffix DOB Sex SSN Ethnicity Marital Status Driver s License # Primary Language English
PRIMARY INSURANCE TO FILE SECONDARY INSURANCE TO FILE
Social Security #: Date: Full Name: Street Address: City: State: Zip: Mailing Address: City: State: Zip: Home Phone #: Employer/School: Employer Address: Date of Birth: Occupation: Work Phone #: Email:
Acknowledgment of Receipt of Notice
Acknowledgment of Receipt of Notice patient acknowledgment I acknowledge receipt of a copy of Maximum Mobility s Notice of Privacy Practices with an effective of January 1, 2012. printed name of patient
PATIENT INFORMATION. Home Address: Phone Numbers: Primary Work . Whom may we thank for referring you? EMPLOYMENT INFORMATION. Employer: Position:
Patient Registration Form Rev. 2017 PATIENT INFORMATION Patient Name: Today s Social Security Number: (Last 4 Digits) Birth Gender: Male Female Marital Status: Married Single Widowed Divorced Home Address:
Signature: Print Name: Date:
~ PLEASE PRINT CLEARLY ~ LAST ADDRESS FIRST MI HOME PHONE SOCIAL SECURITY # EMPLOYER WORK PHONE DATE OF BIRTH JOB/ PROFESSION: CELL PHONE MARITAL STATUS SPOUSE S SPOUSE S SOCIAL SECURITY # (If under spouse
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Email Date of
Bellingham Arthritis & Rheumatology Center. 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F)
Bellingham Arthritis & Rheumatology Center 470 Birchwood Avenue, Suite C, Bellingham, WA 98225 (P) 360-734-5754 (F) 360-734-0586 Patient Name SSN Last First M.I. Date of Birth Age Sex: Male Female Address
The comfort of home, the care of professionals
Gary K. Fowers, MD Barry A. Noorda, MD David A. Kirkman, MD Anne S. Blackett, DO The comfort of home, the care of professionals #P2 Amy Billings, PAC Anna Lara, PAC D Anne Moon, CNM Kenneth A. Wade, PAC
Georgia Foot & Ankle
Georgia Foot & Ankle PLEASE PRINT CLEARLY Today s Date / / Name Date of birth / / First MI Last SSN Marital Status M S D W Age Weight Height Male Female Address City State Zip Phone (Home) (Work) (Cell)
PATIENT REGISTRATION
PATIENT REGISTRATION Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) of Birth Age Male / Female Marital Status: S M W D Address
GENERAL INFORMATION. Scott D. Kazdan, D.O., LLC 601 N. Flamingo Road, Suite 209 Pembroke Pines, FL Phone (954) Fax (954)
Scott D. Kazdan, D.O., LLC 601 N. Flamingo Road, Suite 209 Pembroke Pines, FL 33028 Phone (954)442-7616 Fax (954)442-6234 GENERAL INFORMATION PATIENT NAME: DATE: ADDRESS: CITY: STATE: ZIP: HOME PHONE:
Address: City: State: Zip: Home#: ( ) Mobile#: ( ) Work#: ( ) Date of Birth: / / Age: Sex: SS#: - -
Date of Appointment: Patient's Legal Name: Email Address: (Your email will enable your patient portal access to your medical records) Address: City: State: Zip: Home#: ( ) Mobile#: ( ) Work#: ( ) Date
Do you have or have you ever had any of the following: Circle Yes (Y) or No (N)
PATIENT MEDICAL HISTORY FORM West Georgia Urology Associates, P.C. 150 Clinic Avenue, Suite 202 Carrollton, GA 301117 Phone:( 770) 834-6988 Fax: (770) 834-1090 Today s Date: Name: _ (Last) (First) (Middle
PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Last Name First Name Address City, State, Zip Email Address Home Phone Work Phone Cell Phone SS# Date of Birth Age Sex ( ) Male ( ) Female Marital Status (check one):
SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120
SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120 You have been scheduled for an appointment with Dr. Nandi. At your earliest convenience, please
HIPAA PATIENT CONSENT FORM
HIPAA PATIENT CONSENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing
EMERGENCY CONTACT INFORMATION PATIENT EMPLOYER INFORMATION GUARANTOR / POLICY HOLDER INFORMATION INSURANCE INFORMATION
Physician Name: Kyle F. Dickson, M.D. PATIENT DEMOGRAPHIC INFORMATION SHEET Last Name First Name Middle Social Security No. of Birth Age Male or Female (Please circle one) Marital Status: M S W D (Please
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:(
New Patient Medical Information Survey Revised 3/2013
New Patient Medical Information Survey Revised 3/2013 We are glad you chose the Augusta Surgical Group to meet your surgical needs. Please take a few minutes to fill out this form, as it will help us provide
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
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:
Financial Responsibility
Financial Responsibility This is an agreement between Florida Medical Clinic, P.A., a Florida Corporation, as a creditor, and the Patient/Debtor named on this form. In this agreement the words I, you,
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
Brian D. Haas, M.D., PL PATIENT INFORMATION
Brian D. Haas, M.D., PL PATIENT INFORMATION NAME: Last First M DATE: / / ADDRESS: Street City State Zip Code Married Single Widowed Divorced Social Security # Sex: M F Birthday: / / RACE: ETHNICITY: PRIMARY
ABOUT YOU NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT MAILING DOCTOR S NAME: PLEASE EXPLAIN: DOCTOR S NAME: RESULTS: GOOD BAD INDIFFERENT VITAMIN C
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: WHO REFERRED YOU TO OUR OFFICE? ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT APPLY): NEWSPAPER
Olathe Chiropractic S. Mur-Len Road - Olathe, KS Dr. Jeremy Landry Dr. Joseph Anderson New Patient Intake Form
Olathe Chiropractic 15930 S. Mur-Len Road - Olathe, KS 66062-8301 Dr. Jeremy Landry Dr. Joseph Anderson New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial
Arizona Retina Associates
PATIENT INFORMATION PLEASE PRINT CLEARLY AND COMPLETE ENTIRE FORM Name FIRST MIDDLE INITIAL LAST SUFFIX (Jr., etc.) Address STREET CITY STATE ZIP Age Birthdate SS# Marital Status S M D W Sex M F Occupation
2014 Patient Information
2014 Patient Information Last Name: First Name: Date of Birth: Telephone #: Address: City, State, Zip: Employed Retired Disabled Employer: Telephone #: Primary Care Physician Name: Primary Care Physician
PATIENT HISTORY FORM. DOB: Age: Male Female Marital Status. Address: Preferred Method of Contact: Home Cell Work Text
PATIENT HISTORY FORM Name: SSN: (Last) (First) (MI) DOB: Age: Male Female Marital Status Address: (Street) (City) (State) (Zip) Home Phone: Cell: Work: Email Address: Preferred Method of Contact: Home
Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N
Chief Complaint Form: Patient Name: Date: First MI Last Preferred Name Age: DOB: Occupation: Employer: Send Note? Referring Physician: Town: Y N Primary Care Physician: Town: Y N Coach/ Trainer/ Team Doctor:
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
Name SS# Date of birth / / Gender Ethnicity. Mailing Address City/State ZIP. Marital Status Spouse Name. Phone# Cell# Work#
PATIENT INFORMATION (Please print clearly) Today s date / / Name SS# of birth / / Gender Ethnicity Mailing Address City/State ZIP Marital Status Spouse Name Phone# Cell# Work# EMERGENCY CONTACT PERSON
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
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:
Joshua A. Greenwald, MD Cosmetic Surgery Associates of Westchester
Joshua A. Greenwald, MD PATIENT INFORMATION Name: First Middle Last Age: DOB: / / Social Security Number: - - Month Day Year Address: Street City State Zip Email: Home Phone: ( ) Work Phone: ( ) Cell Phone:
Ronald E. McFarland M.D. PATIENT REGISTRATION AND HISTORY
Ronald E. McFarland M.D. 2021 Church Street, Suite 606 Nashville, TN 37203 PATIENT REGISTRATION AND HISTORY Date: Primary Care Doctor: Name: Sr. Jr. Address: Street City State Zip Code Telephone: Home
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: (
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
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
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Patient Name: DOB: Address: ADDRESS CITY, STATE, ZIP SSN: Mailing Address: ADDRESS CITY, STATE, ZIP Same as above Home phone: Cell phone: Work phone: Marital Status: Single /
Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -
New Patient Forms Today s Date: Name (Last, First, MI): Date of Birth: Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): _ Home Phone: _ ( ) Cell Phone: _ ( ) Work Phone:
Patient Registration Form
Arizona Retina Institute Patient Registration Form Patientʼs Name:" " " " " " " Todayʼs Date:" /" / Patientʼs Social Security#" " " " " Date of Birth:" /" / Gender: Male " Female Marital Status: Single
Your Name: Today s Date: Doctor: Your Address: Date of Birth: Age: Social Security #: Address: City: State: Zip Code: Home #: Cell#: Work#:
ALLAN HERSKOWITZ, M.D., F.A.C.P. BERNARD GRAN, M.D. BRAD HERSKOWITZ, M.D. PAUL DAMSKI, M.D. SERGIO JARAMILLO, M.D. ALBERTO PINZON, M.D. Your Name: Today s Date: Doctor: Your Email Address: Date of Birth:
Patient Information PREFERRED CONTACT PHONE # Today s Date. Name DOB Age Sex Marital Status. City/State/Zip. Home Phone Cell Phone Work Phone
Patient Information Today s Date Name DOB Age Sex Marital Status Address Apt# City/State/Zip Home Phone Cell Phone Work Phone PREFERRED CONTACT PHONE # Email Address Employed By/Occupation Employers Address
PATIENT REGISTRATION SOCIAL SECURITY NUMBER:
PATIENT REGISTRATION LAST NAME FIRST NAME MI M/F ADDRESS APT CITY STATE ZIP BIRTHDATE AGE MARITAL STATUS HOME PHONE SOCIAL SECURITY NUMBER: OCCUPATION: EMPLOYER NAME: WORK ADDRESS: WORK PHONE: PLEASE INDICATE
Patient Name Sex: M F Today s Date. Social Security Number Date of Birth Age. Ethnicity: Hispanic Non-Hispanic Refuse to report
Patient Information Patient Name Sex: M F Today s Date Marital Status Name of Spouse (if applicable) Social Security Number Date of Birth Age Preferred Language: English Spanish Other Ethnicity: Hispanic
TriValley Primary Care. First Appointment Checklist. Forms: Please download, complete and sign the following forms prior to your first visit.
First Appointment Checklist Forms: Please download, complete and sign the following forms prior to your first visit. Patient Registration Form Medical History form or Pediatric History form Financial Responsibility
AUTHORIZATION FOR MEDICAL RECORDS REQUEST/ RELEASE OF RECORDS
AUTHORIZATION FOR MEDICAL RECORDS REQUEST/ RELEASE OF RECORDS PATIENT NAME: DOB: You are hereby authorized to release/receive any medical notes, reports, labs, operative reports and films to/from Zaki
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 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
Surgical Group of Gainesville, PA
Surgical Group of Gainesville, PA REGISTRATION FORM Peter Sarantos, MD* FACS Bruce W. Brient, MD* FACS Stanley V. DeTurris, MD* FACS Brian E. Pickens, MD* FACS Timothy A. Hipp, MD* FACS Jeffery Jeffrey
Advanced Diabetes & Endocrine Medical Center, P.A.
PATIENT REGISTRATION FORM Primary Care Physician Referring Physician Patient s Name: (Last) (First) (Middle) Address: Marital Status: S / M / D / W City/State/Zip: Social Security: Male / Female Date of
How did you learn about our office? Patient s Last Name: First: MI: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )
Date: / / How did you learn about our office? Patient s Last Name: First: MI: Sex: Male Female Date of Birth: / / Age: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Social
New Patient Packet. Thank you for choosing Shasta Regional Medical Group. Our office looks forward to serving you.
New Patient Packet Thank you for choosing Shasta Regional Medical Group. Our office looks forward to serving you. Prior to your appointment: Please complete the attached New Patient Paperwork. Be sure
Wayne Foot & Ankle Center, P.A.
Patient last Name: First Name: Middle : Date of Birth: Age: SSN: Marital Status: Single: Married: Widowed: Divorced: Address: City: Zip code: Email Address: Home Phone # : Cell Phone #: Employer: Occupation:
PATIENT INFORMATION NOTICE OF PRIVACY POLICY PATIENT ACKNOWLEDGEMENT
PATIENT INFORMATION ( MR / MRS / MS / DR ) FIRST MIDDLE LAST DATE OF BIRTH AGE MARITAL STATUS (circle one) Married / Divorced / Single / Widowed STREET ADDRESS APT/LOT/ROOM/SUITE CITY STATE ZIP GENDER
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:
Family Medicine Center of the Bitterroot, P.C.
PATIENT REGISTRATION / FINANCIAL AGREEMENT Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges
Any pertinent medical records
Hello, and welcome to Arizona Pulmonary Specialists, Ltd. You are scheduled to see on at. Please plan to arrive 20 minutes prior to this time. If you are unable to keep this appointment for any reason,
I have read and acknowledge all of the above policies associated with Pioneer Cardiovascular Consultants, PC including: (PLEASE INITIAL)
PH:(480) 345-0034; F:(480)345-4033 Patient s Name (Last) (First) (M.I.) SS# Date of Birth / / Marital Status Sex Race :( optional) Ethnicity: (optional) Preferred language: Referring Physician: _ Phone#:
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
Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext. Date of Birth: Sex: M F Social Security Number:
PATIENT INFORMATION Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext Date of Birth: Sex: M F Social Security Number: Patient E-mail Address: Marital Status:
ADVANCED VEIN & VASCULAR SOLUTIONS Board Certified Vascular Surgeons
ADVANCED VEIN & VASCULAR SOLUTIONS Board Certified Vascular Surgeons We would like to thank you for choosing Advanced Vein & Vascular Solutions for your care. We are committed to providing you with quality
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail:
First Name: MI: Last Name: Address: City: ST: Zip: County: Referring Physician: Home Phn: Work Phn: Cell Phn:
PATIENT INFORMATION First Name: MI: Last Name: Address: City: ST: Zip: County: Email: Referring Physician: Home Phn: Work Phn: Cell Phn: Social Security #: Drivers License #: Age: BirthDate (mm/dd/yy):
San Diego Spine and Sports Wellness. Please Print Below
San Diego Spine and Sports Wellness Date Please Print Below Patient Name SS# Address Apt# City State Zip Code Birth Date / / Age Circle one: Marital Status: S / M / D / W Male or Female Spouses Name Spouse
West Houston Infectious Disease Associates. Address: Number Street Apt. No. City State Zip. Home Phone: Cell: Work:
Carson T. Lo M.D. West Houston Infectious Disease Associates Linda S. Yancey, M.D. NEW PATIENT INFORMATION Thank you for choosing West Houston Infectious Disease Associates. Please completely fill out
NEW PATIENT INFORMATION
1240 EAGLES LANDING PARKWAY SUITE 100 STOCKBRIDGE GA 30281 PHONE 770) 506-0100 FAX 770) 507-2597 NEW PATIENT INFORMATION Print Name: DOB: / / SSN: - - Gender: Age: Race: Marital Status: Employment Status:
PATIENT INFORMATION FULL NAME First M.I. Last CONTACT INFORMATION
PATIENT INFORMATION FULL NAME First M.I. Last DATE OF BIRTH SOCIAL SECURITY # M / D / Y AGE: SEX: MALE or FEMALE STREET APT/SUITE #: CITY, STATE, ZIP City State Zip INSURANCE NAME POLICY/MEMBER ID: HOME
Tri-Valley Internal Medicine Group New Patient Registration Form
Tri-Valley Internal Medicine Group New Patient Registration Form Patient Information Patient s Last Name First Name MI Sex M F Patient s of Birth Age Social Security # (Billing/Identification Purpose)
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
Insurance Information:
Name Address Social Security # Date of Birth City State Zip Sex Marital Status Home Phone # Work Phone # Cell# Employer Occupation Race: Employed: Full Time Part Time Retired Student: Full Time Part Time
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
Island ObGyn Joseph F. Lang, MD
Island ObGyn Joseph F. Lang, MD Patient Name: Billing Address: City: ST: Zip: Other Address: City: ST: Zip: of Birth: Social Security Number: Home Phone #: Work Phone #: Cell Phone #: Email Address: Pharmacy: