NORTH COUNTY GASTROENTEROLOGY MEDICAL GROUI, INC Waring Road, Suite A Oceanside, CA (760) Fax (760)
|
|
|
- Russell Golden
- 5 years ago
- Views:
Transcription
1 Appointment Date: Time: NORTH COUNTY GASTROENTEROLOGY MEDICAL GROUI, INC Waring Road, Suite A Oceanside, CA (760) Fax (760) Thomas C. Krol, M.D. M. Eric Viernes, M.D. Michael Shim, M.D. Information Forms Christopher E. Devereaux, M.D. Javaid A. Shad, M.D., M.B.A. Eva J. Skulsky, PA-C., M.P.A.S. Sara I. Andolina, NP-C. Welcome to the office of North County Gastroenterology Medical Group, Inc. We are located near the In City Medical Center in Oceanside, CA. You may call us at the above number if you need detailed directions. Our appointment times are very limited. With our backlog of patients needing appointments we believe it is not fair to other patients when an appointment time goes unused. Please read and complete the enclosed forms. It is very important that they be completed and brought with you to your appointment. 1.) MEDICAL HISTORY 2.) MEDICATION & ALLERGY LIST (On the medication list please list the name of the drug, the strength, and how you are taking the drug. Please include any vitamins or dietary supplements that you are taking and list the type of allergic reaction you have to a medication, i.e. rash, itching, swelling etc.) 3.) PATIENT INFORMATION FORM 4.) PATIENT FINANCIAL RESPONSIBILITY FORM Before making the trip to the office, please remember the following: 1. We need you to bring your completed forms noted above. 2. For scanning and security purposes, we need your actual insurance card(s) and a photo ID. Be prepared to pay any insurance co-payments. If you arrive without your card(s) or co-pay your appointment will have to be rescheduled. 3. Please arrive at the office 15 minutes prior to your scheduled appointment to complete the check-in process. INSURANCE INFORMATION: As a courtesy to you and per any contractual agreement with your insurance, we will file claims with your primary and secondary insurance carriers only, provided you have given us all necessary information (i.e. current insurance cards and correct billing address). If you have more than two policies, you are responsible for fi ing claims with a third and any subsequent insurance carriers. Co-pays are collected for each visit at check-in. Office visit co-pays will be collected at time of check-in. We accept cash, checks, or credit cards (please be aware that we cannot break $100 bills). Please be advised we have a $25.00 fee you will be charged for any returned checks. FINANCIAL RESPONSIBILITY: Please refer to the "Patient Financial Responsibility Form". See #1. Financial Responsibility. North County Gastroenterology Medical Group, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. North County Gastroenterology Medical Group, Inc. cumple con las leyes federales aplicables de derechos civiles y no discrimina por motivos de raza, color, origen, nacional, edad, discapacidad, o sexo. Revised 02/02/2017 PATIENT INFORMATION FORM
2 North County Gastroenterology Medical Group 3923 Waring Road Suite A Oceanside, Ca
3 WELCOME TO NORTH COUNTY GASTROENTEROLOGY Please use black ink. Date PATIENT NAME: Acct; MALE FEMALE AGE DATE OF BIRTH MARITAL STATUS: S M W D ADDRESS: Please circle one: Apt. Unit Space # City: State: Zip: HOME PHONE: ( ) CELL: ( ) Preferred contact number (please circle one): Home Cell Work Preferred Language: Race: White/Caucasian 0 Black/African American 0 Asian O Hispanic/Latino 0 Native Hawaiian/other Pacific Islander O Other 0 Unknown 0 Decline to provide Ethnicity: Hispanic/Latino O Non-Hispanic/Latino O DeCline to provide EMPLOYER: ADDRESS: OCCUPATION: WORK PHONE: ( ) SS #: DRIVER'S LICENSE #: STATE: SPOUSE OR RESPONSIBLE PARTY: DOB: SS #: EMPLOYER: WORK PHONE: ( ) PERSON TO NOTIFY IN EMERGENCY: HOME PHONE (if different): RELATIONSHIP: ADDRESS: PHONE: ( ) WHO IS YOUR PRIMARY CARE DOCTOR? WHO REFERRED YOU TO OUR OFFICE? INSURANCE INFORMATION AS A COURTESY we will bill your primary and secondary insurance carrier if you provide ALL necessary information (such as insurance cards and/or completed and signed claim forms if your carrier requires it and their CORRECT billing address). HMO co-pays are collected for each visit at check-in. A $25.00 FEE WILL BE CHARGED FOR ALL RETURNED CHECKS. Insurance Name: Claims address: PRIMARY SECONDARY Policyholder Name: Policyholder DOB: Policyholder ID: Group ID or #: SIGNATURE OF PATIENT OR LEGAL GUARDIAN: X For billing purposes, we require this form to be fully completed. We reserve the right appointments due to incomplete forms or tardiness. Please let us know within 48 hours if yoi your appointment. to reschedule any are unable to keep 02/02/2017
4 PATIENT FINANCIAL RESPONSIBILITY FORM Patient Name: Date: The physicians of North County Gastroenterology Medical Group, Inc. require this form to be signed by our patients. We appreciate your cooperation..if you have ANY questions, please ask the receptionist. FINANCIAL RESPONSIBILITY (3 Scenarios): 1. If I have no insurance I understand that I will be personally responsible for any medical fees I will incur with North County Gastroenterology Medical Group, Inc. OR 2. If I have an HMO or coverage by a State or Federally funded program with which North County Gastroenterology Medical Group, Inc. is contracted, I agree that I will be responsible for any charges incurred if I DO NOT provide my most current and correct insurance to the office at the time of my services. I understand I will need a current authorization for my services from my Medical Group. OR 3. If I have insurance I understand I will be personally responsible for any deductibles, coinsurance or co-pays that my insurance coverage determines. I agree to furnish up-to-date insurance information and a current insurance card whenever having services in the office. I have read and agree to the terms above that apply to me. AUTHORIZATION TO RELEASE OR OBTAIN INFORMATION: I HEREBY AUTHORIZE North County Gastroenterology Medical Group, Inc. to release or obtain medical information acquired in the course of my examination or treatment, to or from my insurance company, or other physicians required to participate in my care or for the purpose of processing my claim. AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment for medical services provided directly to the North County Gastroenterology Medical Group, Inc. physicians. Signature of Insured or Patient: X It is our policy to leave medical information, such as normal blood test results, norma biopsy results on your answering machine, or with someone residing at your home. By signing below, I agree with this policy, otherwise speak with the receptionist. Below: To be signed at time of check in: ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY POLICY: I acknowledge that I have received a copy of North County Gastroenterology Medical Policy. roup's Privacy Date: 02/
5 NORTH COUNTY GASTROENTEROLOGY MEDICAL GROUP, INC. TRI-CITY GASTROENTEROLOGY MEDICAL GROUP, INC Waring Road, Suite A Oceanside, CA Phone (760) FAX (760) NAME: PRIMARY DOCTOR: DATE OF BIRTH: AGE: REFERRING DOCTOR: CHIEF COMPLAINT: PHYSICIAN'S COMMENTS (HPI): Do you have a pacemaker or a defibrillator? (If yes, we need to copy your card) yes no Are you taking any blood thinners? Aspirin, Plavix, Coumadin, etc yes no Have you ever seen a stomach, colon, or liver specialist: (Gastroenterologist)? yes no If yes, name of Doctor: Have you ever had any of the following tests? YES NO Colonoscopy or Sigmoidoscopy Upper endoscopy (EGD) Stomach xray (upper GI) Colon xray (Barium Enema) Gallbladder ultrasound CT scan of your abdomen Have you ever had any of the following medical problems? YES NO Colon polyps Colon cancer Colitis Diverticulitis Ulcers Hepatitis, Liver problems Gallstones Pancreatitis Are you currently experiencing any of the following problems? YES NO Abdominal pain Heartburn Bloating Nausea Vomiting Trouble swallowing, Food getting stuck Change in bowel habits Constipation: hard stools Constipation: infrequent stools Diarrhea Black stools Rectal bleeding Yellowness of skin or eyes (Jaundice) Weight loss (unintentional) Milk causes gas Milk causes diarrhea Wheat causes digestive problems Continued on other side/next page
6 REVIEW OF SYSTEMS: If you are experiencing any of the problems listed below, please circle them. GENERAL Fevers Chills Fatigue PSYCHIATRIC Changes in mood Depression Anxiety EYES Change in vision Red eyes ENT Changes in hearing Hoarseness Sore Throat RESPIRATORY Shortness of breath Cough Wheezing CARDIAC Chest Pain, Palpitations Dizziness Heart Murmur GU Difficulty Urination Blood in Urine JOINTS & MUSCLES Joint pains Muscle pains Difficulty walking NEURO Muscle weakness Difficulty with speech Recent stroke SKIN / Rash Skin Changes Swelling in ankles or legs EXTREMITIES ENDOCRINE Feeling too hot Feeling too cold HEME / LYMPH Easy bruising Easy bleeding History of low blood counts (anemia) LIST ALL PAST AND PRESENT MEDICAL PROBLEMS LIST ALL SURGERIES DATE MEDICAL PROBLEMS DATE SURGERIES FAMILY HISTORY Have any relatives ever had any of the following diseases? State Relationship YES NO and agg at time of diagnosis. Esophageal Cancer Stomach Cancer Colon Cancer Colon Polyps Ulcerative Colitis Crohn's Disease Other Cancers SOCIAL HISTORY Tobacco Now? YES NO How much? packs per day How long? years If quit, when did you stop? How much alcohol do you drink? per day or Current or Previous Profession: Marital Status: S M D W Average weight lbs or kg How much caffeine do you drink? per week 02/02/2017
7 NORTH COUNTY GASTROENTEROLOGY MEDICAL GROUP MEDICATION & ALLERGY LIST Patient name: Your Pharmacy: Pharmacy address: Pharmacy phone number: Do you have a pacemaker or a defibrillator? If yes, please bring your card with you. It is very important that you bring this completed list to your appointment. List all medications you are taking by name, the strength of each dose and how often you take it. Include hormones, diet pills, vitamins, cold tablets and over the counter laxatives, herbs, enzymes, aspirin, etc. Medication Dosage / Strength (example: mg) What are the directions on the prescription / bottle? Please use other side if necessary STATE LAW REQUIRES YOU LIST YOUR ALLERGIES AND TYPE OF REACTION Please list your ALLERGIES: Medications, foods, or other items (i.e. latex) What type of REACTION do you aye? Please use other side if necessary Chief Complaint (why are you seeing the doctor today?): 02/02/2017
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
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
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:
PATIENT INFORMATION. First:
PATIENT INFORMATION Patients last name: First: MI: Street Address: PO Box: Birth date: / / City: State: Zip Code: Marital status: Sex: Male or Female Social Security: 1st phone: 2nd phone: Email address:
ADVANCED GASTROENTEROLOGY RESEARCH & ENDOSCOPY CENTERS
NEW PATIENT QUESTIONNAIRE Family Physician: Patient s Social Security #: (Social security number mandatory) Address: e-mail address: I understand that my e-mail will only be used for educational information.
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:
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
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
CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY
CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY Name Age Date of Birth Email _ Reason for today s visit Who referred you to this office _ Who is your primary care physician? Are you allergic
FORMS MUST BE COMPLETED IN FULL
1 Nurse Use Only: Height: Weight: Temp: BP: / Pulse: Flu: Pneumonia Mammogram Patient Health Information Patient Name: DOB: Today s Date: How did you hear about us/referring physician: Reason for Today
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 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
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
***PLEASE PRINT USING BLACK INK ONLY***
***PLEASE PRINT USING BLACK INK ONLY*** 100 Hospital Lane, Suite 220 Danville, IN 46122 HOME PHONE WORK PHONE CELL PHONE PHARMACY LOCATION PHONE # NAME SS# ADDRESS CITY STATE ZIP BIRTHDATE AGE HEIGHT WEIGHT
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]:
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):
Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:
PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally
appointment checklist
appointment checklist Dear parents: The staff of Cook Children s Pediatric Gastroenterology (GI) and Nutrition Clinic appreciates your selection of our physicians to serve you and your child s needs. Our
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)
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
DIGESTIVE DISEASE SPECIALISTS, INC. INSTITUTE OF DIGESTIVE DISEASE DDSI AEC SOUTH LLC
PATIENT INFORMATION FULL LEGAL NAME (No Nicknames) DIGESTIVE DISEASE SPECIALISTS, INC. INSTITUTE OF DIGESTIVE DISEASE DDSI AEC SOUTH LLC MR. MRS. MS. MISS LAST NAME FIRST MI DATE: DDSI PROVIDER: PREFERRED
PATIENT COPY ONLY. Patient Name:
Patient Name: Appt. Date Start Time: Patient Payment Policy for Gastroenterology Consultants, P.C. Dear Patient, Your insurance company may pay all, a portion, or none of your bill for services performed
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:
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:
Orthopaedic Specialists, P.L.L.C. PATIENT INFORMATION
Orthopaedic Specialists, P.L.L.C. PATIENT INFORMATION Date: Patient s Last Name First Middle Initial Home Phone No. Street Address City and State Zip Code Cell Phone No. Social Security No. DOB Age Sex
Secondary Insurance Carrier Name of Insured Member ID# Group # Birthdate of Insured / / Employer SS # of Insured / / Relation to Insured
PATIENT MEDICAL & PAYMENT INFORMATION SHEET TODAY S DATE Patient Name Date of Birth: / / Age Local Address Social Security # / / City State Zip Code Home Phone # ( ) - Permanent Address Cell Phone # (
Byron J. Van Dyke, M.D. Medical, Surgical, & Cosmetic Dermatology 1158 N. Court Street, Redding, CA Tel (530) Fax (530)
PATIENT: Date of Birth Gender: Male Female Ethnicity: Hispanic Non-Hispanic Single Married Divorced Widowed Race: Caucasian/European-American African/African-American Asian/Asian-American Native American
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:
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 #:
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
Endocrinology of the Rockies, PC. PATIENT REGISTRATION FORM E. 9th Ave. Ste. 245, Denver, CO 80220
1 PATIENT REGISTRATION FORM 2018 4545 E. 9th Ave. Ste. 245, Denver, CO 80220 Patient Name (Last, First, M.I.): Prefer to be called: Address: City: State: Zip: Home phone: ( ) Work phone: ( ) Day phone:
ROCKWALL SURGICAL SPECIALISTS
PATIENT REGISTRATION FORM Patient s name (Last, First, Middle Initial) Sex (M or F) Date of Birth Address City State Zip Home Phone Cell Phone Email Marital Status Social Security Number Driver s License
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:
ROCKWALL SURGICAL SPECIALISTS
ROCKWALL SURGICAL SPECIALISTS Dr. David Ritter Dr. Ashley Egan Dr. Jon Harris Phone (972) 412-7700 Fax (972) 412-7710 PATIENT REGISTRATION FORM Patient s name (Last, First, Middle Initial) Sex (M or F)
Other Scan(s): List All Your Medical Diagnosis: Chemotherapy? YES NO If yes, please list treatment regimen:
Patient Name: Today s Date: Preferred Language: Date of Birth: Age: SSN: Race: Ethnicity: Home Phone: Cell Phone: Work Phone: Best contact phone number should we need to reach you about your treatment:
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
PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
PATIENT INFORMATION SHEET
Dr. Ricky Bare, F.A.C.S. Dr J.G. Cargill III Dr. James Brien Dr. Michael Burris Dr. H. Brooks Hooper Kimberly Bullock, FNP DATE: PATIENT INFORMATION SHEET PATIENT NAME: FIRST MI LAST SOCIAL SECURITY NUMBER:
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 - -
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
ERIC ROCKMORE, DPM, FACFAS
Date: Name Date of Birth Address City State Zip Code Email Address Preferred Language Social Security(Medicaid only) Referred by Gender Race Ethnicity Home# ( ) Work # ( ) Cell ( ) Preferred phone # (
New Patient Registration Guide
Endocrinology New Patient Registration Guide Please use this form to fax or email back to our office at least 1 day prior to your appointment. TO: New Patient Registration FROM: FAX: 301-977-5151 DATE:
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
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
ERIC ROCKMORE, DPM, FACFAS STEPHANIE HORLING, DPM, FACFAS
OFFICE USE ONLY Date: Photo I.D. Initial Name Date of Birth Address City State Zip Code Email Address Preferred Language Social Security(Medicaid only) Referred by Gender Race Ethnicity Home# ( ) Work
***PLEASE PRINT USING BLACK INK ONLY***
***PLEASE PRINT USING BLACK INK ONLY*** 100 Hospital Lane, Suite 220 Danville, IN 46122 HOME PHONE WORK PHONE CELL PHONE PHARMACY LOCATION PHONE # NAME SS# ADDRESS CITY STATE ZIP BIRTHDATE AGE HEIGHT WEIGHT
LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# ADDRESS:
PATIENT INFORMATION LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# EMAIL ADDRESS: OCCUPATION: EMPLOYER: RACE: ETHNICITY: White
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,
PATIENT NAME: SEX: M / F DATE OF BIRTH: AGE: S.S# ADDRESS: Street: City: State: Zip Code:
Plastic Surgery Specialists, P.C. Dennis T. Monteiro, M.D., F.A.C.S. Emely J. Karandy, D.O., F.A.C.O.S. John T. Louis, M.D., F.A.C.S. William C. Dilks, C.R.N.P. Diana B. Bragoli, C.R.N.P PATIENT NAME:
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Widowed
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
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:
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
Gastroenterology - West
Gastroenterology - West Welcome to The Oregon Clinic, Gastroenterology-West! We are pleased that you have chosen us to provide your gastrointestinal care. Please complete the attached forms and bring them
PATIENT INFORMATION. PATIENT NAME Last First M.I. Social Security Number. ADDRESS Street DATE OF BIRTH SEX Female Male
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Divorced
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 /
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
Social Security No: Home Phone: _. Employer: Work Phone: _. Employer Address: Occupation: _. Spouse/Parent Name: Phone No: _
THE NATIONAL RETINA INSTITUTE LEADERS IN THE TREATMENT OF RETINAL DISEASES Patient Information Form Patient Name: Date of Birth: -,--I _----'--/ Age: Social Security No: Home Phone: _ Street 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
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
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
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 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: (
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
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:
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
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
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,
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,
DIGESTIVE DISEASE SPECIALISTS, INC. INSTITUTE OF DIGESTIVE DISEASE DDSI AEC SOUTH LLC
PATIENT INFORMATION FULL LEGAL NAME (No Nicknames) DIGESTIVE DISEASE SPECIALISTS, INC. INSTITUTE OF DIGESTIVE DISEASE DDSI AEC SOUTH LLC MR. MRS. MS. MISS LAST NAME FIRST MI DATE: DDSI PROVIDER: PREFERRED
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
GASTROENTEROLOGY ASSOCIATES, P.C./ADVANCED DIGESTIVE CARE, LLC
GASTROENTEROLOGY ASSOCIATES, P.C./ADVANCED DIGESTIVE CARE, LLC PATIENT HISTORY Patient Name: Date of Birth: Age: Today s Date: Referring Doctor: CHIEF COMPLAINT: Drug Allergies: Reactions: Current Medications:
Laguna Woods Dermatology
Laguna Woods Dermatology Patient Registration Form Visit date: Name: First Middle Last of Birth: Social Security Number: Nickname (optional): Sex: M F Address: Street City State Zip Mr. Mrs. Dr. Home Phone:
PATIENT INFORMATION INSURANCE INFORMATION
DATE REFERRED BY CHART # PATIENT INFORMATION NAME: (first) (middle initial) (last) BIRTH DATE: / / GENDER: FEMALE MALE SOCIAL SECURITY #: ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE: WORK PHONE: MOBILE
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
Buckland Ear, Nose & Throat, LLC. Medical History
Buckland Ear, Nose & Throat, LLC Medical History Patient Name: Today s Date: Primary Care Provider: Referred by: Pharmacy You Use: Date of Birth: Age: Name City 1. Reason for visit: 2. Past Medical History:
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
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 #: /
PATIENT REGISTRATION FORMS
PATIENT REGISTRATION FORMS Last Name: First Name: Middle Initial: DOB: / / Street Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - SSN: - - Sex: M / F Email: (for patient portal purposes
Prefix Last First Middle Suffix. Maiden Gender SSN Marital Status Date of Birth
Prefix Last First Middle Suffix Maiden Gender SSN Marital Status Date of Birth Race Ethnicity Primary Language Address Line 1 Address Line 2 United States Zip City State Country Home Phone Cell Phone Work
Gastroenterology Specialists, Inc.
Email Address: John R. Hood, M.D. Michael J. Martin, M.D. William K. Briggs, M.D. Jeffrey L. Bigler, M.D. 10210 East 91st Street South Tulsa, Ok 74133 (918) 940-8500 Gastroenterology Specialists, Inc.
Welcome To Our Office Please Print
1 PATIENT INFORMATION Date Home Phone ( ) E-mail Street City State Zip Marital Status Children? Ages Occupation May we call you at work? Y N Work Hours SPOUSE/DOMESTIC PARTNER INFORMATION (If appropriate)
Date: Medical History DOB:
Date: Medical History DOB: 1. Name: Age Right handed Left handed 2. Occupation: _ 3. Describe problem (be specific) 4. Duration of symptoms: 5. Date of Injury: Work Injury No Yes Dates you have been off
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
Patient Information Packet Date:
Patient Information Packet Date: We know paperwork is not fun, but thank you so much for taking the time! Last Name: First Name: M.I. Address: Phone: City State: Zip Code: Mobile: Date of Birth: / / Social
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS NAME: LAST FIRST MIDDLE ADDRESS: STREET APT# CITY STATE ZIP HOME # ( ) WORK# ( ) CELL# ( ) E-MAIL: PREFERENCE: HOME: AGE: DATE OF BIRTH: SS NO.: MALE
Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS
WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions we ll be glad to help you. We look forward to
PATIENT REGISTRATION
PATIENT REGISTRATION Last Name First Name Middle or Maiden Mailing Address City County State Zip Physical Address (if different) Telephone: Home( ) Cell ( ) Work ( ) Preferred Contact: Home Cell Text Message
Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:
PATIENT INFORMATION Today s : / / Patient Name (Last, Middle, First) Social Security #: Male / Female: of Birth: / / Street Address: Email Address: Home Phone: Mobile Phone: Work Phone: IF THE PATIENT
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
Medical History. 12. List all previous Surgeries and Date of Procedure (Orthopedic or otherwise):
Date: Medical History DOB: 1. Name: Age o Right handed o Left handed 2. Occupation: 3. Describe problem (be specific): 4. Duration of symptoms: 5. Date of Injury: Work Injury: o No o Yes Dates you have
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. 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
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
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
Patient Health History Form
Patient Health History Form PATIENT INFORMATION Patients Legal Name: Name that child likes to be called (Nickname): DOB: Current Age: SOURCES OF INFORMATION Name of Person Providing Information: Relationship
Patient Registration Form
Patient Registration Form PATIENT INFORMATION Please Print Last Name: First: M.I. Mailing Address: City: State: Zip Code: Date of Birth: Gender: M F Married Single Widowed Divorced Separated Partnered
PATIENT INFORMATION. Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Main Contact#: Alternate#: Work#:
PATIENT INFORMATION Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single
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
STEVENS FAMILY CHIROPRACTIC METROPOLIS AVE, SUITE 101 FT MYERS, FL (239) Patient Intake Form. Sex: Male Female.
Patient Intake Form : Name: Sex: Male Female Address: City: State: Zip: Home Phone: Cell Phone: Preferred Phone: Email Address: Social Security #: Of Birth: Occupation: Marital Status: Single Married Divorced
PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
PATIENT INFORMATION Gary S. Fields, DPM, FACFAS Kenneth M. Danis, DPM, FACFAS DEMOGRAPHICS First Name Middle Initial Last Name Gender SSN Birthdate Age Email M F Mailing address: Apt # City: State: ZIP