Who is responsible for this account? ls patient covered by additional rnsurance? n Yes I No. Subscriber's Name INSURANCE ASSIGNMENT AND RELEASE.
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- Lynette Harriet Reed
- 5 years ago
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1 Who is responsible for this account? )t, SS/HlC/Patient ld #.., Patient Name ) Address Frrst Name Middle Initial ls patient covered by additional rnsurance? n Yes I No Subscriber's Name zip n Married I Widoweo E SeParated n Divorced Birthdate! Single n Minor! Partnered lor _ years INSURANCE ASSIGNMENT AND RELEASE I certify that I have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr insurance benefits, if any, othemise payable to me for services rendered I understand that I am iinancially responsible for all charges whether or not paid by insurance I authorize the use of my signature on all insurance submissions,'ll The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services This consent will end when my current treatment plan is completed or one year from the date signed below MEDICARE/MEDIGAP AUTHORIZATION Home Phone (_) Cell Phone (_) Best time and place to reach you I requesthat payment of authorized lvledicare benelits and, if applicable, lvledigap benefits, be made either to me or on mv behalf to Name o{ - for any services Doctoi-i Cltrilc furnished to me by that provider To the extent permitted by law, I authorize any holder of medical or other iniormation about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benelits or benefits for related services.r'll Please print name of Beneficiary, Guardian or Personal Representative Work Phone (_) Date Rehtibnshio to eneficiarv What is the chief complaint for which you came to be treated? (lnclude foot, ankle, knee, thigh, and hip complaints.) lf vac nleaco lict Name Last visit ls there any personal or family history of diabetes? Your occupation Cigarette/Tobacco use Years smoked Athletic activities in which you participate (please list and indicate frequency) Please indicate which foot problems you now have or have had in the oast. Ankle Pain Athlete's Foot Bunions Corns and Calluses Cramps or Numbness Flat Feet Foot or Leg Cramps Heel Pain Ingrown Toenails Plantar Warts Swelling in Ankles or Feet Tired Feet in Feet or Legs [Yes! No IYes I No IYes I No IYes E No lyes E No EYes I No fyes n No F-l Vac tr Yes nno ENo
2 Place a mark on "Yes" or "No" to indicate if vou have had anv of the followino: AIDS/HIV Epilepsy Allergies to Anesthetics lyes n No Allergies to Medicine or Drugs! Yes n No Anemia EYes! No Angina IYes n No Arthritis Artificial Heart Valves or Joints I Yes n No Asthma Back Problems Bleeding Disorders Cancer Chemical Dependency Chest Pain Chronic Diarrhea Circulatory Problems Diabetes Ear Problems Surgeries you have had IYes E No IYes! No nyes! No nyes E No nyes E No Eye Problems Fainting Foot or Leg Cramps Gout Headaches Heart Disease Hemophilia Hepatitis or Jaundice High Blood Pressure Kidney Problems Liver Disease Low Blood Pressure Neuropathy Phlebitis Psychiatric Care Radiation Treatment nyes X No nyes f No EYes n No IYes n No IYes n No tryes n No lyes! No lyes tr No lyes n No Rash Respiratory Disease Rheumatic Fever Shortness of Breath Sinus Problems Special Diet Stroke Swelling in Ankles, Feet Swollen Neck Glands Tired Feet Tuberculosis Ulcers Varicose Veins Venereal Disease Weight Loss, unexplained nyes! No EYes n No tryes n No lyes E No IYes E No EYes I No IYes I No EYes I No Hosoitalization other than for the suroeries listed Family physician Are you now, or haveyou been, under any other doctor's care for any reason over the past two years? lf yes, please explain Last visit date lyes f No Include prescriptions, over-the-counter medications and vitamins Do you take oral contraceptives?!yes tr No I Adhesive/Tape! Anticoagulant Therapy tr Aspirin I Codeine f I Other Demerol lodine n Local Anesthetics! Novocaine n Penicillin n Seafoods n Su[a I hereby consent and give my permission to the doctor (and the doctor's assistants or designated replacement) to administer and perform such procedures upon me as the doctor deems necessarv. Signature of Patient, Parent, Guardian or Personal Representative Please print name of Patient, Parent, Guardian or Personal Representative
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WELCOME. Date: Patient Name: Social Security #: Address:
WELCOME PATIENT INFORMATION: Date: Patient Name: Social Security #: Address: Email: Sex: Male Female Age: Birthdate: Married Separated Widowed Single Divorced Minor Partnered for years Patient Employer/School:
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M.
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. 10801 Lockwood Drive, Suite 260 Silver Spring, Maryland 20901 (301) 439-0300 3408 Olandwood Ct., Suite 204 Olney, Maryland 20832-1367
o 5801 Allentown Road, Suite 305 Camp Springs, MD 20746
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. o 10801 Lockwood Dr., Suite 260 Silver Spring, MD 20901 ph. (301) 439-0300 Ix. 681-1488 o 3408 Olandwood Court, Suite 204 Olney, MD 20832
Welcome to Central Florida Foot and Ankle Center
What is the chief complaint for which you came to have treated? Have you ever been to a Podiatrist before? Yes No If yes, please list. Name Last Visit Shoe size: Weight: Height: Is this injury/problem
Jeffrey T. Molinaro, DPM, FACFAS
101 Dixie Drive 1170 NILES CORTLAND RD Oakdale, PA 15071 NILES, OH 44446 PHONE # 412-787-8380 PHONE # 330-544-4141 FAX # 412-787-1099 FAX # 330-544-4134 DATE Jeffrey T. Molinaro, DPM, FACFAS LAST NAME
Welcome to Central Florida Foot and Ankle Center, LLC
Welcome to Central Florida Foot and Ankle Center, LLC PATIENT INFORMATION Patient Name Address City State Zip Mailing Address City State Zip SS# DL# E-Mail Sex M F Age Birth Married Widowed Single Minor
General Vital Information
509 Stillwells Corner Road, Ste. E9 Frrehold, NJ 07728 General Vital Information Today s Date: Name: Nickname: Sex: M / F SS #: DOB: E-mail: Address: City: State: Zip: House #: Work #: Cell #: Preferred
Fixing Feet Institute W. Bell Rd., #100 Surprise, AZ Phone: Fax:
We are pleased to Welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. This information will enable our physicians to take better care of your concerns.
PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
Dr. Peter F. Gregory, D.P.M. Patient s Name: Date: / / Address: City State Zip Date of Birth: / / Sex: Male Female Home Phone: Cell Phone: Business Phone: Email: (Please check preferred method of contact
Fixing Feet Institute W. Bell Rd., #100 Surprise, AZ Phone: Fax:
We are pleased to Welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. This information will enable our physicians to take better care of your concerns.
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI BIRTH DATE MARRIED SINGLE MINOR MALE FEMALE MONTH DAY YEAR SOCIAL SECURITY # ADDRESS STREET APT. # CITY STATE ZIP I would like my appointments
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PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
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PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)
PATIENT INFORMATION Patient s Full Name: (First) (Middle) (Last) Birth date: Age: Race: Sex: [ ] Female [ ] Male Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed SS# Address: City: State:
PATIENT INFO: Occupation: Employer: Phone: Emergency Contact: Phone: IF MINOR: Parent Name: SS#: DOB:
PATIENT INFO: DATE: Name: SS#: DOB: AGE Address: City/State: Zip: Sex: ( ) Male ( ) Female Home Phone: Cell Phone: Occupation: Employer: Phone: Emergency Contact: Phone: IF MINOR: Parent Name: SS#: DOB:
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA (619)
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All Dental 76 Otis Street Westborough, MA 01581
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Dental Registration and History
~) Patient Information (PLEASE PRINT) ftj. Dental Insurance Date Who is responsible for this account? SS/HIC/Patient ID # Relationship to Patient. Patient Name----,------,--,-, Last Name Insurance Co.
Cheyenne Foot & Ankle
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Prince Family Dentistry
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PATIENT REGISTRATION
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Patient Registration
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Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information
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PATIENT REGISTRATION
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Candace L. Peterson, DMD
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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:
WELCOME TO PRAIRIE GARDEN DENTAL. Responsible Party/Primary Insurance Holder If different from above
WELCOME TO PRAIRIE GARDEN DENTAL Patient Information Date Name Preferred Name Birthdate Social Security # Female Single Married Divorced Widowed Separated Other Home Address Employer Occupation Home Phone
DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS OR CONCERNS? (Circle all correct responses)
Name How do you wish to be addressed of Birth Reason for today s visit Former dentist Reason for leaving of last dental visit Reason for last dental visit How often do you brush? How often do you floss?
Welcome! Your Appointment Details: Day: Date: Time: am / pm. Please arrive 15 minutes prior to your appointment time.
Welcome! Dear New Patient, Thank you for choosing Southern Oregon Foot & Ankle for your podiatric care! Please fill out the enclosed forms and bring them with you to your appointment. Your Appointment
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EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE
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Date of First Office Call: Last Name Legal 1 st Name Middle Name Mail Address City State Zip Secure Phone # PATIENT INFORMATION Date of Birth Sex Marital Status Occupation Name of Spouse or Partner Names
Patient Information. City State Zip Code. Date of Last Dental Visit: Reason for this visit: Health Information
Chart #: Patient Information Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Birth Date: Family Status: Date: Phone (Home): (Work): Ext: (Cell) Email: Street Apartment # City State
Patient Information & Health History Page 1. Date:
Patient Information & Health History Page 1 Patient Information Mr. Mrs. Ms. Dr. First Name M.I. Last Sex: Male Female Birth Date: Age Soc. Sec. # Address City State Zip Home Phone ( ) Cell Phone ( ) Email
Advanced Periodontics & Implant Dentistry of Westchester
Advanced Periodontics & Implant Dentistry of Westchester Patient Name: Social Security #: David L. Sandak, DDS, PC Fara Vossughi, DDS, MS 10 Old Mamaroneck Road, White Plains, NY 10605 Phone: 914-997-1111
Welcome. Patient Name: Social Security #: (Last name) (First name) (Middle Initial) Street Address City State Zip
Welcome Thank you for choosing us for your dental care needs. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to contact us. (206)