Patient Information PREFERRED CONTACT PHONE # Today s Date. Name DOB Age Sex Marital Status. City/State/Zip. Home Phone Cell Phone Work Phone
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1 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 # Address Employed By/Occupation Employers Address & Phone Number Spouse s Name Spouse s Employers Address & Phone Number Emergency Contact/Emergency Contact Phone# Referred By Primary Care Physician
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3 Systems Review Have you ever had or currently have any of the following? General: Weight Loss No / Yes Weight Gain No / Yes Chills No / Yes Fever No / Yes Night Sweats No / Yes Eyes: Glaucoma No / Yes Double Vision No / Yes Pain No / Yes Glasses/Contacts No / Yes Redness No / Yes Loss in Vision No / Yes ENT: Hearing loss No / Yes Ringing in Ears No / Yes Infections No / Yes Pain No / Yes Redness No / Yes Nosebleeds No / Yes Hoarseness No / Yes False Teeth No / Yes Seasonal allergies No / Yes Pulmonary/Respiratory: Cough No / Yes Phlegm No / Yes Coughing up blood No / Yes Wheezing No / Yes Asthma No / Yes Tuberculosis No / Yes Pneumonia No / Yes Emphysema No / Yes Snoring No / Yes Sleep Apnea No / Yes Gastrointestinal Heartburn No / Yes Indigestion No / Yes Ulcers No / Yes Constipation No / Yes Diarrhea No / Yes Blood in Stool No / Yes Black Stool No / Yes Gallbladder disease No / Yes Hepatitis No / Yes Abdominal Pain No / Yes Polyps No / Yes Psychiatric: Anxiety No / Yes Depression No / Yes Panic disorders No / Yes Suicidal thoughts No / Yes Drugs/alcohol abuse No / Yes Musculoskeletal: Arthritis No / Yes Back/Neck/Hip pain No / Yes Bursitis No / Yes Sciatica No / Yes Joint Swelling No / Yes Neurologic: Strokes No / Yes Migraines No / Yes Frequent headaches No / Yes Seizures No / Yes Memory Loss No / Yes Numbness/Tingling No / Yes Genitourinary: Stones No / Yes Kidney disease No / Yes Blood in urine No / Yes Herpes No / Yes HIV/AIDS No / Yes Other: Family Medical History (Please Update Changes Since Last Annual Exam) Check here if there are no changes since your last visit. Age Diseases If Deceased, Cause of Death Father: Mother: Brother: Sister:
4 COMPLETE CARDIOLOGY, P.C. PRACTICE FINANCIAL POLICY If you have medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy. Co-payments for office services are required at the time you register. As a courtesy, we will process and file your insurance claims for services at no cost to you. For services that are covered by insurance, the practice requires payment of approximately 20% of the total estimated charges or the co-payment specified by your insurance. For services that are not covered by insurance, the practice requires payment of 100% of total charges unless payment arrangements have been worked out. Returned checks are subject to a handling fee of $ In the event your account must be turned over for collection, you will be billed and are responsible for all fees involved in that process. You must realize that: 1. Your insurance is a contract between you and your employer and/or the insurance company. While we may be a provider of services, we are not a party to that contract. We encourage you to contact your insurance carrier personally in order to remain informed of your benefits. 2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover or which they may consider medically unnecessary, and, in some instances, you will be responsible for these amounts. We will make every effort to ascertain your coverage for our services before treatment and will make you aware of our findings. However, this does not guarantee payment from your insurance carrier. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. We will allow you 90 days to pay any balance remaining after insurance payment. After that time, your account will accrue interest at the rate of Prime plus 2%. Our staff will make arrangements for you to make monthly payments over an approved term. If you have any questions about the above information, or any uncertainty regarding your insurance coverage, please do not hesitate to ask us. We are here to help you. PLEASE READ THE ABOVE CAREFULLY BEFORE SIGNING. acknowledge that I have read and understand this policy. By signing below, I Signature: (Patient and/or Responsible Party) Date: Copyright 2014 Medical Management Associates, Inc. All Rights Reserved.
5 To all of our patients at Complete Cardiology Complete Cardiology is dedicated to ensuring your privacy. Please answer each privacy question and inform the Front Desk staff of any changes that may apply to you: I authorize you to leave messages on my home answering machine regarding appointments and to inform me of laboratory/test results Yes No I authorize you to contact or leave messages at my place of work Yes No I authorize you to discuss my medical information with my family. Please provide family Members names Yes No I authorize you to view my external prescription history and I understand that prescription history from other medical providers and insurance companies may be included. Yes No Signature Date Thank you for your cooperation
6 COMPLETE CARDIOLOGY, P.C. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I, (print Patient s name), acknowledge and agree that I have received a copy of Complete Cardiology, P.C s Notice of Privacy Practices. Patient Signature Patient Legal Representative (if applicable) Print Name of Legal Representative Date Date Relationship to Patient FOR PRACTICE USE ONLY: Complete Cardiology, P.C s made the following good faith efforts to obtain the above-referenced Patient s written acknowledgement of receipt of the Notice of Privacy Practices: , v. 1 Complete Cardiology, P.C s HIPAA Manual Tab 2 Acknowledgment of Receipt of Notice of Privacy Practices
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,
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:
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):
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
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 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
New Patient Packet Please print and complete the following 6 pages. Bring the completed forms to your scheduled appointment. Thank you!
New Patient Packet Please print and complete the following 6 pages. Bring the completed forms to your scheduled appointment. Thank you! Washington Ear, Nose and Throat 80 Landings Drive, Suite 207 Washington,
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
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S EMAIL: DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE
Arthur M. Cotliar, M.D. & Staff
Dear Patient: Thank you for taking time to schedule an appointment at one of our offices. Please fill out the enclosed forms and bring the forms with you on the day of your appointment. In addition, please
INSTRUCTIONS. Once you complete the forms, save the file to your desktop for your records, then attach in an to:
INSTRUCTIONS For your convenience you can fill out the following forms on your computer if you have Adobe Acrobat Reader installed. Fields are highlighted in blue. Use the tab key to move from field to
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?
ADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
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]:
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
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Name: Primary Phone: Secondary Phone Address:_ City: State: Zip: Social: Age: DOB: Height: Weight: Primary Physician: _ Referral Source: Email Address: HISTORY Chief Complaint:
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Name: Primary Phone: Secondary Phone Address: City: State: Zip: Social: Age: DOB: Height: Weight: Primary Physician: Referral Source: Email Address: HISTORY Chief Complaint: Where
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
PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Name Date Street Address City State & Zip Home Phone ( ) Sex Age Date of Birth Cell Phone ( ) Email Address Race Primary Language Employer Occupation Work Phone ( ) May we
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,
Patient s Full Legal Name: DOB: Sex: M F. SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip:
Patient Information: Date: Patient s Full Legal Name: DOB: Sex: M F SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip: Home Phone: Cell Phone: Daytime Phone: Email: Approved Communication:
Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
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
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S EMAIL: DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE
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:
Consent For Treatment
Consent For Treatment I hereby give my permission for Piedmont Neurology, LLC (the Practice) to provide diagnostic services and medical treatment. I permit the Practice to file for insurance benefits to
Patient Registration Form
Patient Registration Form Date: Name: Maiden Name: (First) (MI) (Last) SSN: Birth Date: Age: Marital Status: Sex: M or F Race: Ethnicity: Language: Mailing Address: City: State: Zip: Physical Address:
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
ROBERT H. OLIVER, M.D., PLLC Otolaryngology Head And Neck Surgery Otolaryngic Allergy Chart #
Chart # PATIENT INFORMATION Please Print, Complete Fully, And Return To The Front Desk Circle One: Mr. Mrs. Ms. Miss. Dr. Child Please Circle: Sex: Male Female Marital Status: S M Other Widowed Patient
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,
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:
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
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
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
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 Information Form
ALASKA DIGESTIVE AND LIVER DISEASE, LLC Ronald J Boisen, M.D. Daryl M. McClendon, M.D. Jeffrey W. Molloy, M.D. Patient Information Form Patient s Name: Age: DOB: Sex: Male Female Marital Status: S M W
Tri-Valley Internal Medicine Group Registration Form
Registration Form Patient Information Patient's Name: Last Name First Name DOB Age Sex: M F Patient Address: City: State: Zip Code: Home Number: Cell Number: Must have patient SSN# for Billing Purpose
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:
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
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
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
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:
Montville MedSpa & Pain Center
New Patient Registration First Name: Last Name: Middle Initial: Address: Date of Birth: Social Security Number: Home Phone: Cell Phone: Work Phone: Email Address: Sex: Male Female Marital Status: Single
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:
PATIENT FORM. Whom do we contact in the event of an emergency? Name: Relationship: Parent / Child / Spouse / Other: Home #: Cell#: Alternate #:
PATIENT FORM Patient Name: DOB: / / SSN# Sex: Male / Female Age: Status: Married / Single / Divorced / Separated / Widowed Address: City: State: Zip: Alternate Address: City: State: Zip: Home #: Cell#:
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 FORM
PATIENT REGISTRATION FORM Full Name: Date of Birth: Address: City/State/Zip: Social Security: - - Marital Status: Home Phone: Cell Phone: Email address: Gender: Male Female Is the patient in a Nursing
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
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
PAYMENT POLICY: Payment or partial payment is required on the day of visit.
Patient Information Date Patient Name (First) (M.I.) (Last) Date of Birth SSN Gender Male Female Transgender-Male Transgender-Female Marital Status Race Ethnicity Preferred Language Patient Address City
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:
Greater Austin Allergy, Asthma & Immunology
Greater Austin Allergy, Asthma & Immunology phone: (512) 732-2774 fax: (512) 329-6871 PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Sex Single Married Widowed Divorced Present Address City,
Marietta Podiatry Group Patient Registration Form
Marietta Podiatry Group Patient Registration Form CHART # 1. Patient Information (Please include all information as shown on insurance card.) Patient s Last Name Patient s First Name Date of Birth 2 Gender:
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
BRAMLETT ORTHOPEDICS
BRAMLETT ORTHOPEDICS 200 Montgomery Highway, STE 200 Birmingham, AL 35216 Patient Information Phone: 205-783-5900 Fax: 205-783-5906 Patient Information Name (Last, First, Middle) Social Security Number
X PRINT PATIENT S NAME DATE OF BIRTH SIGNATURE
Surgery Partners Affiliated Covered Entity (SPACE) 2017 ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I have received the attached Privacy Notice. X PRINT PATIENT S NAME DATE OF BIRTH
PATIENT INFORMATION. Patient s Last Name First M.I. Home Phone Work Phone Cell Phone Home Address City State Zip Address
PATIENT INFORMATION Patient s Last Name First M.I. Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Address Social Security # Sex Marital Status Patient s Date of Birth Age Spouse s
3 Name: DOB: Chart Number: Sex: M F Marital Status: Single Married Widowed Divorced SS# Employer: Phone: Address:
Practice: Lance Berlin, DPM Today s Date: 3 Name: DOB: Chart Number: Sex: M F Marital Status: Single Married Widowed Divorced SS# E-Mail: Spouse/Partner Name: Address: City: State: Zip: Home #: Cell #:
Patient Information. Name Date. Address City Zip. Age Date of Birth / / Marital Status M S D W. Social Security # Driver s License #
Patient Information Name Date Address City Zip Age Date of Birth / / Marital Status M S D W # of Children Social Security # Driver s License # May Ashby Chiropractic Clinic communicate with you by: Telephone
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
ANN BULLINGTON, M.D. ROBERT H. BULLINGTON, JR., M.D. Cornea and External Diseases AILEEN F. VILLAREAL, M.D. ROBERT E. FINTELMANN, M.D., F.A.C.S. Cornea, Cataract, and Refractive Surgery Welcome to Biltmore
Greenbriar Vision Center Welcomes You Please Print Clearly
Greenbriar Vision Center Welcomes You Please Print Clearly First Name Last Name Today s Date Address City State Zip Code Home # Work # Cell # Email Sex: Birth date: Age: Parent/Guardian s name (if patient
Princeton and Rutgers Neurology, P.A. A Center Of Excellence
DEMOGRAPHICS Patient s Last Name: First Name: Address: City: State: Zip Code: Tel # (Cell): Tel # (Home): Tel # (Work) #: Preferred Method Of Contact: [] Cell Phone [] Home Phone [] Work Phone SS #: /
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE
Surgery Partners Affiliated Covered Entity (SPACE) 2018 ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I have received the attached Privacy Notice. PRINT PATIENT S NAME DATE OF BIRTH AGREEMENT
Tri-Valley Internal Medicine Group Registration Form
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CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA (360)
CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA 98223-1668 (360) 435-6097 M.C. WHITMAN III, M.D., FACS PETER WOLFF, M.D., FACS DEAR You have been referred to Cascade Surgeons, the office of Dr. Whitman
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
about us? Birth Date Age SS# Marital Status (circle one) Single Married Widowed Divorced Spouse s Phone No. Spouse s Employer Race (optional)
Patient s Name Nickname Referring Physician Address Preferred Phone No. Sex (circle one) Male Female Patient s Employer City/State/Zip Alternate Phone No. Email How did you hear about us? Birth Date Age
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Patient
New Patient Intake Form
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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
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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:
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
Surgical Group of Gainesville, PA
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Phone: (512) Fax: (512)
Phone: (512) 732 2774 Fax: (512) 329 6871 NEW PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Gender Single Married Widowed Divorced Address/City/State/Zip Email: Cell phone Occupation (if minor,
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
Cardholder Name: Patient Name: Relation to Patient: Sex: Cardholder s DOB: Co-pay: Member ID#: Group #:
2121 Whitesburg Drive, Suite C Huntsville, AL 35801 Name: DOB: Sex: Age: Address: City: State: Zip Code: Primary Phone: Secondary Phone: SSN: Preferred Language: Race: Employer: Occupation: Work Phone:
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
Birth Date: Age: Sex: Ethnicity: Carrier: Cardholder's Name: Carrier: Cardholder's Name:
Patient Information Patient's Last Name: First: MI: Social Security Number: Birth Date: Age: Sex: Ethnicity: Street Address: City: State: ZIP Code: Home Phone: Cell Phone: Work Phone: E-Mail Address: Referring
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / /
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y. 14814 DATE: / / PATIENT INFORMATION FORM (PLEASE PRINT) PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX:
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
1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.
Thomas J. Savage, DPM Jay H. Dworkin, DPM PC 1421 S. Potomac Street, Suite 120 Aurora, CO 80012 303.923.3369 www.metrofoot.org 303.923.3882(fax) Please print and complete all parts. Date PATIENT INFORMATION
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Address: How did you hear about us? Name: Date of Birth: / / Address: City: State: Zip code: Phone Number: HOME - - WORK - - CELL - - EMPLOYER:
Date of Appointment: / / Email Address: How did you hear about us? Have you been seen here before? YES NO If YES, WHEN?: PATIENT INFORMATION Name: Date of Birth: / / AGE: SSN: - - GENDER: Male Female Marital
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
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 #:
Patient Information. Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Address: Home Away Address: City: State: Zip:
Patient Information Date: Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Male Female Social Security #: Birth Date: / / Age: Local Phone: ( ) Cellular Phone: ( ) Email Address:
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
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
Welcome to Biltmore Eye Physicians! Enclosed in our new patient packet are the following items: 1. Patient Registration 2. Credit Policy and Financial Agreement 3. Notice of Privacy Practices 4. Medical
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,
PATIENT REGISTRATION
7521 Virginia Oaks Drive #240 Gainesville, VA 20155 Ph: 703-753-7600 PATIENT NAME (FIRST, MIDDLE, LAST) PATIENT REGISTRATION DATE: HOME PHONE HOME ADDRESS CELL PHONE CITY STATE ZIP CODE SOCIAL SECURITY
INFECTIOUS DISEASE TROPICAL MEDICINE & TRAVEL CLINIC
INFECTIOUS DISEASE TROPICAL MEDICINE & TRAVEL CLINIC HOW DID YOU HEAR ABOUT OUR OFFICE? DEMOGRAPHICS LAST NAME FIRST NAME MIDDLE INITIAL SOCIAL SECURITY NUMBER SEX PREFIX/SUFFIX DATE OF BIRTH (mm/dd/yy)
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 Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided.
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided. Last Name: First Name: Primary Care Physician: Referring
Patient Registration. Mailing Address: Alternate Phone#: Pharmacy Address: Insurance Information. Primary Insurance Name: Name of Insured/Subscriber:
Patient Registration Patient Name: Social Security #: DOB: Sex M F Marital Status: Mailing Address: Primary Phone#: Alternate Phone#: Primary Care Physician: Preferred Pharmacy: Home Phone#: Email: Referring
HEALTH QUESTIONNAIRE NAME SEX AGE DOB HEIGHT WEIGHT PLACE OF BIRTH REASON FOR VISIT
HEALTH QUESTIONNAIRE NAME SEX AGE DOB HEIGHT WEIGHT PLACE OF BIRTH REASON FOR VISIT LIST OF MEDICATIONS: (IF ADDITIONAL SPACE IS NEEDED, PLEASE CONTINUE ON THE BACK OF THIS PAGE) DRUG DOSE FREQUENCY YEAR
REGISTRATION FORM (Please Print)
Today s date: REGISTRATION FORM (Please Print) PATIENT INFORMATION PCP: Patient s Last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal
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
VALLEY ENT superior medical care, right in your neighborhood
Please be aware that certain procedures performed in our office are not included under the standard office visit. These procedures are billed separately and in addition to office visit charges. Some insurance
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