DERMATOLOGY CLINIC OF N MS, PLLC (662)
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1 DERMATOLOGY CLINIC OF N MS, PLLC (662) Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name MRN: Last First Middle Initial Mailing Address Street & Apt # City State Zip Code Home Phone Cell Phone Age: Birthdate: SS#: Gender: Race*: Ethnicity*: Preferred Language*: *Optional. For government purposes only. The Dermatology Clinic of N MS, PLLC does not discriminate on the basis of sex, race, ethnicity, religion, or disability. For more information, please see our Non-discrimination policy. RESPONSIBLE PARTY (if patient is a minor) Last First Middle Initial Relationship to patient: Birthdate: SS#: Gender: PATIENT S EMPLOYER Occupation: Work phone number: N/A Patient is a student or child. Is it ok to call you at work? Yes No Industry: Extension: N/A Patient is retired. RELEASE OF INFO RESTRICTIONS (Please include the person s NAME; not just the relationship) Ok to release info to the following: Ok to leave treatment info, lab results, prescription info on: Home Answering Machine Cell Voice Mail None Contact me only Emergency contact (not in your household): Home number: Work number: PRIMARY CARE PHYSICIAN Name: Group Name: Office Phone PREFERRED PHARMACY Pharmacy Number
2 DERMATOLOGY CLINIC OF N MS, PLLC (662) Patient: MRN: PRIMARY HEALTH INSURANCE COMPANY: Policy Number: Insured: Name Employer Relationship to patient Group Number: DOB SS# Gender SECONDARY HEALTH INSURANCE COMPANY: Policy Number: Group Number: Insured: Name DOB Employer SS# Relationship to patient Gender AUTHORIZATION TO SUBMIT INSURANCE CLAIMS I,, authorize Dermatology Clinic Of N MS, PLLC to bill my insurance company for services rendered. If necessary, copies of my medical record may be submitted with my claim. _Here NON DISCRIMINATION POLICY I,,have reviewed the non-discrimination policy of Dermatology Clinic Of N MS, PLLC. I understand that Dermatology Clinic Of N MS, PLLC complies with applicable Federal civil rights laws and does not discriminate or treat differently on the basis of race, color, national origin, age, disability, or sex. I also understand my rights to necessary language interpretation. Here HIPAA NOTICE I,, have read or received a copy of the notice of privacy protection, which outlines how Dermatology Clinic Of N MS, PLLC protects your privacy and maintains HIPAA standards. Here
3 FINANCIAL POLICY YOU COULD BE RESPONSIBLE FOR YOUR ENTIRE BILL!!! If you have any questions about the following policy, please ask the receptionist or manager. We want to do our best to provide the most accurate information for you. PAYMENT IS DUE AT TIME OF SERVICE: Any co-pays, co-insurances, unmet deductibles, and fees for noncovered services are due at the time of service. With many insurance companies changing their regulations, patients are now subject to a higher financial burden. That means YOU MAY HAVE TO PAY MORE MONEY OUT OF POCKET BEFORE YOUR INSURANCE COMPANY WILL PAY TOWARD YOUR MECIAL EXPENSES. We will try to make you aware of your benefits and financial responsibilities. All self-pay patients must also pay their bill in full at the time of service. NON-COMPLIANCE WITH PAYMENT: We are contractually required to collect the amount specified by your insurance company. Depending on the insurance company, we may be required to report if you refuse to pay your co-payment, coinsurance, or unmet deductible. If we are forced to report non-compliance to your insurance company, you could lose your insurance benefits. MEDICAID PATIENTS: Our office currently accepts Mississippi Medicaid and Mississippi United Health Care Community Plan. We do not accept TN Care of any kind, Magnolia, Ambetter, or any other Medicaid. If you have one of the plans we do not accept, we will not be able to treat you in our office as you must seek care from a provider contracted with your insurance company. DIVORCE AGREEMENTS: If you are bringing your child in for an appointment and your ex-spouse is obligated to you to pay for medical treatment through your divorce decree, we will try our best to accommodate your situation. HOWEVER, the parent bringing the child in for the appointment and signing this document is the one financially responsible to us. If your ex-spouse does not pay the bill, it will ultimately be your responsibility; not that of the ex-spouse. OVER PAYMENTS AND BILLING: If you overpay on your account, we will refund to you the amount you have overpaid after all services have been paid. We will bill you for any unforeseen amounts that were not collected at the time of service. Please be sure to inform us of any change in address, phone number, or employment. All balances are due in full within 14 days of the first billing date. PAST DUE AND DELINQUENT ACCOUNTS: We can notify credit bureaus, transfer your account to a collection agency, or take other collection actions against you if you do not pay your bill. You can also be terminated as a patient from our office. All attorney fees, court costs, and other expenses accumulated while collecting payment will be added to your outstanding balance. Checks that are returned will be subject to a $40 returned check fee as well as Section Mississippi Code of If a patient has written us a bad check, we will be unable to accept any more checks from the patient. OUTSIDE LABS: If you have a culture taken or a growth/mole/lesion/etc removed, we will send the specimen to an independent lab for examination by a pathologist. We want to send the specimen to a lab that is in your network, BUT in-network status changes often. If you are unsure which lab we should use, please contact your insurance company. NO SHOW/SAME DAY CANCELLATIONS: In the event that you need to cancel your appointment, we ask for 24 hour notice. If you have a same-day cancellation or no-show for your appointment, you will assess a $25 fee. BY SIGNING BELOW, I HAVE READ, UNDERSTAND, AND AGREE TO THIS POLICY. ature Patient Name:
4 Patient Name: MEDICATION LIST of Birth: Do you currently take any medications (including topical/rub-on medications) either prescribed or over the counter: YES (list below) NO NAME OF MEDICATION DOSEAGE DOCTOR WHO PRESCRIBED Do you have any allergies: YES (list in table below) NO No know drug allergies ALLERGEN REACTION
5 Patient Name: Height: Weight: DOB: MRN: Do you now or have you ever had disease, condition of, or problem with the following: (Please check YES or NO) LUNGS YES NO OTHER SYSTEMIC YES NO Tuberculosis Depression COPD/Emphysema Suicide attempts Asthma Rheumatoid Arthritis CARDIOVASCULAR Diabetes Type 1 or 2? CAD Insulin Dependent? Valve replacement Kidney failure w dialysis Defibrillator Other kidney Problem: Pacemaker Hepatitis A, B, or C? PVD HIV HTN Thyroid Disease Stroke Bladder Problem: Atrial Fibrillation Prostate Cancer: On blood thinners/aspirin Stomach Problem: Cholesterol/triglycerides Inflammatory bowel SKIN YES NO Crohn s disease Intentional tanning/tanning bed Ulcerative Colitis Skin Cancer Cancer (not of skin) Type: Type if known YES NO Type: FAMILY HISTORY YES NO Organ Transplant Organ: Skin Cancer YES NO Organ: If yes, who? Joint Replacement Joint: What type if known? Joint: SOCIAL HISTORY What is/was your occupation? Are you married? Yes No SMOKING STATUS AND ALCOHOL USE Are you a smoker? No, never smoker No, former smoker Yes, current smoker If current/former smoker: smoking start date & end date Do you drink alcohol? Yes No Men: How many times in a year do you drink more than five (5) drinks in a day? Women: How many times in a year do you drink more than four (4) drinks in a day? VACCINES Have you had your flu shot? Yes No If yes, approx. date: If over 65, have you had your pneumonia shot? Yes No If yes, approx. date: FEMALES ONLY : (Please check if applicable) Currently pregnant Planning pregnancy soon Breastfeeding Irregular periods Excessive hair (face/body) On birth control; Type: Patient ature: :
DERMATOLOGY CLINIC OF N MS, PLLC (662)
DERMATOLOGY CLINIC OF N MS, PLLC (662) 349-0200 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name MRN: Last First Middle Initial Mailing
Are you interested in receiving information about special promotions? Yes! No thanks.
1600 N Coalter St, Ste 19 Staunton, VA 24401 Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON
GREENWOOD DERMATOLOGY
GREENWOOD DERMATOLOGY Larry J. Buckel, M.D. Thomas J. Eads, M.D. Laura T. Stitle, M.D. Thank you for choosing Greenwood Dermatology for your Dermatologic needs. Dermatologists are the experts in the diagnosis
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
PATIENT REGISTRATION (Please Print)
PATIENT REGISTRATION (Please Print) DATE: PATIENT INFORMATION Patient s Name: SS #: (First) (Middle) (Last) Street Address: Apt. #: Male 9 Female 9 Age: Patient s Date of Birth: Home ( ) Cell ( ) Email
Mailing Address: Name: FIRST MIDDLE LAST. Mailing address: If different from patient. Telephone Numbers: Home Day Number
Dermatology Center South PC 2800 Ross Clark Circle, Suite 2 DOTHAN, ALABAMA 36301 REGISTRATION FORM FOR DEPENDENTS] Patietnt Name: First Middle Initial Last of Birth: / / Sex: Male Female Month Day Year
FINANCIAL POLICY AND AGREEMENT
FINANCIAL POLICY AND AGREEMENT Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be
BIRCH BAY DERMATOLOGY
BIRCH BAY DERMATOLOGY PATIENT INFORMATION Photo ID (State or Federal) Please provide this to the receptionist PATIENT REGISTRATION FORM By providing your contact information below, you are granting permission
Past Medical & Surgical History (Please list any diseases or conditions that you have now or have ever had) (DO NOT LEAVE BLANK)
Date of visit: Name: SS#: - - DOB: / / Race: Ethnicity: Language: Reason for your visit today: Referring physician: PCP: Best number to reach you for your test results: May we leave a message? Yes No Male
NEW PATIENT FORM (please print)
NEW PATIENT FORM (please print) PATIENT INFORMATION Full Name: Male: Female: First Middle Last Street Address: City: State: ZIP: Home Phone: Work Phone: Cell: Birthdate: Occupation: How were you referred:
LUPTON DERMATOLOGY MR# Today s Date:
LUPTON DERMATOLOGY MR# Today s Date: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name: First Middle Last Address: Street & Apt # City State Zip SS#: Birthdate Age: Sex: Female Male Marital Status:
2800 Ross Clark Circle, Suite 2 Dothan, AL
2800 Ross Clark Circle, Suite 2 Dothan, AL 36301 334-677-1690 Minor Patient Registration Form First Name M.I. Last Name Preferred Name: Street Address: Apt, Lot, Suite # City: State: Zip: DOB: Age: Sex:
CENTRAL OHIO PLASTIC SURGERY, INC. (740)
(740) 653-5064 Patient s Name Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Last First Middle Nickname Address Street & Apt # City State Zip Home
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
Alaska Center for Dermatology, P. C Piper Street Suite T4-020 Anchorage, AK telephone fax
3841 Piper Street Suite T4-020 Anchorage, AK 99508 telephone 907.646.8500 fax 907.646.9760 Please print all information clearly. Patient Patient Registration Form Name of Birth / / first middle initial
Would you like to receive our monthly ed newsletter? Yes! No thanks.
Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON RESPONSIBLE FOR ACCOUNT: MAILING ADDRESS: (CITY)
List all medications you are currently taking (including prescriptions, over-the-counter, & vitamins)
10680 Medlock Bridge Rd., Suite 204 Johns Creek, GA 30097 Ph 470.282.5729 Fax 770.674.5795 Dr. Paola Bonaccorsi Dr. Dale Sarradet Patient name: Date of Birth: / / Today's Date: / / Reason for today's visit:
Please Present Insurance Card at Each Office Visit
PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
Medical History Form
Medical History Form Patient Name: Occupation: Why are you here today? Preferred Pharmacy: Pharmacy Phone #: Pharmacy City/Zip: Do you have a primary care physician? Yes No When was the date of your last
Patient Information. Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name:
Patient Information Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name: Date of Birth: / / Age: SSN: - - Address: City: County: State: Zip: Email
William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español
Active feet are happy feet. William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español New Patient Information Form (Please Print) Date: / / Social
PATI ENT INFORMATION Date=----~--- First Name: Ml: Last Name: ------------ Date of Birth: Sex: [ ] Male [ ] Female Address: City,State, Zip: Home Phone: Cell Phone:, Work Phone: Email Address: Marital
615 1 st Street North, Alabaster 1320 Woodfin Lane, Clanton Phone: (205) Fax: (205)
615 1 st Street North, Alabaster WELCOME TO TRUE DERMATOLOGY. PLEASE FILL OUT ALL PERTINENT SECTIONS AND SIGN WHERE INDICATED. TODAY S DATE: / / Last Home Phone#: Check Preferred Contact Number First M.
Patient Information. Medical Insurance/Policy Holder
Patient Information (Print legibly in Blue or Black Ink ONLY) Last Name: First Name: M.I. Address: City: State: Zip: SSN: DOB: Sex: M/F Shoe size: Height: Weight: Race: Home: Work: Cell: Employer: Emergency
**The Dermatology Clinic sends all appointment reminders via text**
PATIENT INITIAL EVALUATION INFORMATION (Adult) DATE Patient Name Date of Birth / / First Middle Last Month Day Year Mailing Address Street City State Zip Home Phone Work Phone Cell Phone **The Dermatology
PATIENT INFORMATION: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) ADDRESS: Street Address City State Zip Code
PATIENT INFORMATION: Date: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) E-MAIL ADDRESS: ADDRESS: Street Address City State Zip Code BIRTHDATE: / / AGE: SSN: SEX: M F OCCUPATION:
MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information
Patient Information Patient Name Last First Middle Address City State Zip Birthdate Age Sex M F Social Security# Race (Please circle) American Indian Asian Black Native Hawaiian Pacific Islander White
PATIENT REGISTRATION FORM. Address. Street# Street Name Apt.# City State Zip Code. Employer: Date of Birth: / / Age Month Day Year
PATIENT REGISTRATION FORM Name: Jr. Sr. First Middle Last Prefer to be called: Gender(Sex): M F Married Divorced Single Widowed Race : White Black Asian Indian Other Declined to Provide Ethnicity: Hispanic
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
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
Patient Registration Form
Patient Registration Form Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /
![PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /](/thumbs/85/92736920.jpg "PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /")
Dr. Osehotue Okojie, M.D. Godwin Okojie, P.A. Patient Registration Form (Please Print) PATIENT INFORMATION PATIENT S NAME: Last name First name Middle Birth Date: / / Sex: [ ] M [ ] F Social Security #:
New Patient Form. Patient Name: DOB: Date: Sex: Race: Social Security Number: Driver s License Number: Address: City/ State/ Zip
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REGISTRATION FORM (Please Print)
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Patient Update Information
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CITRUS ORTHOPAEDIC AND JOINT INSTITUTE PATIENT INFO. SHEET
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PATIENT INFORMATION. Caucasian or White Male Female. Unknown IN CASE OF EMERGENCY
Name (Last, First, Middle Initial): PATIENT INFORMATION Salutation: Mr. Social Security # Preferred Language: Race: Ethnicity: American Indian or Alaska Native Hispanic or Latino Asian Not Hispanic or
APPLETON PLASTIC SURGERY CENTER, S. C. (920)
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Total Care Family Practice 1701 N Green Valley Pkwy Bldg 5-C Evan C. Allen, MD Henderson, NV PH: (702) Fax: (702)
Demographics Last : First : What would you like to be called: Marital Status: Single Married Other Gender: Male Female DOB: Social Security: Email: Address: City: State: Zip Code: Home Ph: Cell Ph: Employment
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,
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
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA (540) PHONE (540) FAX
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first
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Patient Information Sheet (Please Print) Name:
Robert E. Sussman, D.P.M. Evan Adler, D.P.M 2260 Highway 33 Neptune, NJ 07753 (732)-776-7260 Patient Information Sheet (Please Print) Name: Last First MI Address: Street Address City/State Zip Code Home
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PATIENT REGISTRATION / INFORMATION SHEET Name: LAST FIRST MIDDLE Date of Birth: Gender: M F Marital Status: Social Security Number: Email Address*: Street Address: City: State: Zip: Home Phone: Cell Phone:
Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information
Patient Information Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information Today's Date Patient s Name Preferred Name Patient
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
Privacy Practices. Patient Name (please print) Patient Date of Birth. Signature of Patient/Guardian
Privacy Practices I acknowledge that Owensboro Dermatology Association, PSC has provided me a copy of their Notice of Privacy Practices, which provides a detailed description of the uses and disclosures
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION Patient s Name Sex Male Female Date of Birth Address City/State Zip Code Home Phone Cell Phone E-mail address Driver License # Marital
Minor Patient Information
Minor Patient Information MINOR S INFORMATION: (TO BE FILLED OUT BY CUSTODIAL PARENT OR LEGAL GUARDIAN) Last Name: First Name: MI: Goes By (If Different Than Above): DOB: Sex: M F Ethnicity/Race: Preferred
Medicine and Surgery of the Foot PATIENT INFORMATION PERSON RESPONSIBLE FOR PAYING THE BILL FAMILY PHYSICIAN INFORMATION HEALTH INSURANCE INFORMATION
PATIENT REGISTRATION Thank you for choosing our office! Please complete all pages. Patient Name: PATIENT INFORMATION Home Address: City: State: Zip: Sex: S S#: Marital Status: S,M,O or minor E-mail: Home
Completed Application and Required records can be sent by mail or fax to:
KIDNEY AND KIDNEY/PANCREAS TRANSPLANT RECIPIENT APPLICATION LEGAL NAME: GENDER: Male Female (First) (MI) (Last) (Maiden) ADDRESS: DATE OF BIRTH: (Street) (Apt #) MARITAL STATUS: MARRIED (City) (State)
Patient Registration Form Please complete all the information below in print, please do not leave any questions blank. Thank You!
Patient Registration Form Please complete all the information below in print, please do not leave any questions blank. Thank You! PATIENT INFORMATION: Last Name: First Name: Middle: Date of Birth: Home
PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone
![PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone](/thumbs/78/78629552.jpg "PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone")
PATIENT INFORMATION DATE OF VISIT: Date of Birth Gender: M F PATIENT FULL NAME: Address [Apt. # ] City State Zip Email address: Preferred Phone: Secondary Phone: Circle: Single Married Partnered Divorced
PATIENT INFORMATION. Race: Ethnicity:
PATIENT INFORMATION Last name: First: MI: Today s Date: SS#: Mailing Address: Date of Birth: City: State: Zip: Sex: Primary Phone: Home Work Mobile Secondary Phone: Home Work Mobile Tertiary Phone Home
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
Medicare Patient Registration
Medicare Patient Registration Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
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:(
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:
New Patient Information
New Patient Information PATIENT INFORMATION: Last Name: First Name: MI: Preferred Name (If different than above): DOB: Sex: M F Address: Apartment # City: State: Zip Code: Home Phone: Cell: Work: What
PATIENT S INFORMATION
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Villa Medical Arts New Patient Forms
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Medford Foot & Ankle Clinic, P.C.
MICHAEL A. DEKORTE, DPM, FACFAS* RICK E. MCCLURE, DPM, FACFAS* JEFFERY D. ZIMMER, DPM Dear Patient, Thank you for choosing Medford Foot and Ankle Clinic for your podiatric care. Enclosed are the registration
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
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS
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Wilmington Dermatology Center Patient History Form
Print name: Wilmington Dermatology Center Patient History Form Instructions: Please fill out each bubble completely MEDICAL HISTORY History of melanoma O Yes O No History of squamous cell carcinoma (SCC)
West Cary Family Physicians 256 Towne Village Dr Cary, NC
New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s
Patient Last Name: First MI. Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone:
Patient Last Name: First MI Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security No.: Sex: Marital Status:
PATIENT S INFORMATION
PATIENT S INFORMATION Date: DOB: Social Security#: Patient Name: Last Name First Name Middle Name Address: E-mail Address:_ Phone Home: Cell: Work: Marital Status: Sex (Circle) M F Gender Identity (Circle)
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Email Address Street Address City State Zip Social Security Number Cell Phone Home
SOUTH SHORE NEPHROLOGY, P.C.
SOUTH SHORE NEPHROLOGY, P.C. Please fill out this form along with all the documents included in the patient packet and bring it with you for your upcoming appointment. Be sure to bring your insurance card(s)
Office Location and Directions
Office Location and Directions Our office is located at 395 Commercial Court, Suite E, Venice, FL 34292 off Jacaranda near I-75, exit # 193. Turn at traffic light with Hess gas station and McDonald's on
Name: Mr Ms Mrs Dr Last First Initial. Mailing Address: City: State: Zip Code:
Name: Mr Ms Mrs Dr Last First Initial Mailing Address: City: State: Zip Code: Home #: Work #: Cell #: #Preferred: Email: Date of Birth: Age: Sex: F / M Marital Status: M / S / D / W SSN : Employer: Student:
NOTICE TO OUR PATIENTS
NOTICE TO OUR PATIENTS Although we participate with most insurance plans, you as the patient and/or insured party are responsible for co-pays, deductibles and any non-covered services, which are outlined,
Phone Home Work Cell. Other Emergency Contacts Name Name Phone Home Phone Home
FLORIDA HOSPITAL TRANSPLANT CENTER CLINIC DEMOGRAPHIC INFORMATION This application MUST be filled out completely. ALL incomplete applications will be returned to sender Name (First) (MI) (Last) (Maiden)
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
Patient or Parent/Guardian Signature:
Tri State Foot and Ankle Center, LLC Dr. Harold Gruber, DPM Dr. Sandra Hudak, DPM 2018 Naamans Rd. Wilmington, DE 19810 Phone: 302-475-1299 Fax: 302-475-0579 722 Yorklyn Rd. Hockessin, DE 19707 Phone:
13065 W McDowell Rd., Suite C101, Avondale, Arizona Phone: Fax:
Personal Information - Please Print Last Name: First Name: Initial: DOB: SS# Address: Home Phone: Cell: Work: Email: Gender: Language: Marital Status: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Race:
Welcome to Advanced Dermatology
Patients Name Welcome to Advanced Dermatology (First) (Middle) (Last) Today's Date Date of Birth Gender SS# Patient Employer Name City State Phone ( ) Phone ( ) E-Mail Financial Responsible party (Minors
New Patient Information
New Patient Information Patient Title Dr. Mr. Mrs. Ms. Miss Last Name First Name M.I. Address Apt/Ste # City State Zip Date of Birth / / Age Male Female Home Phone Cell Phone Is it ok to leave a detailed
DERMATOLOGIC CENTER FOR EXCELLENCE ANTHONY S. DEE, MD DANIELLE JOHNSTON, RPA-C LISA PORTER, RPA-C PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Date Patient Name: DOB: Sex: M F Address: City/State/Zip: Email: Social Security #: Please provide contact information and indicate your preferred contact number: Home Phone:
COASTAL SKIN SURGERY & DERMATOLOGY
DEMOGRAPHIC INFORMATION Last Name: First: Middle: Date of Birth: Age: Sex: M F Marital Status: SSN: Race: Ethnicity: Hispanic or Latino Not Hispanic or Latino Language: Mailing Address: Street apt/unit#
MISSION STATEMENT. Our office endeavors to provide our patients with prompt, competent, and courteous care while offering the
MISSION STATEMENT Our office endeavors to provide our patients with prompt, competent, and courteous care while offering the best leading edge podiatric care possible. PRACTICE S REQUIREMENTS The Practice
Saline Heart Group, PA
www.salineheartgroup.com Patient Account # Date: Patient Information In order for us to provide you with the best possible care, please fill out these forms as completely and accurately as possible. Last
Christine LaComb, RN, FNP-C th Street Suite B Groves, TX (409) Phone (409) Fax
Christine LaComb, RN, FNP-C 6000 39 th Street Suite B Groves, TX. 77619 (409) 962-8509 Phone (409) 962-0763 Fax Welcome To Our Practice! In Order To Properly Serve You, Please Complete The Following Forms
PLEASE PRINT CLEARLY
PATIENT INFORMATION FORM Rev. 02/2018 PLEASE PRINT CLEARLY New Patient Name Change Address Change Insurance Policy/Holder Change PATIENT INFORMATION Last Name: _ First Name: Middle Initial: DOB: Sex: Male
GARRAMONE PLASTIC SURGERY (239)
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
Please be aware that payment of all office visits and services are due at the time of your visit.
Dr. David A. Amato All About Faces Community Dermatology 1 West Main Street Hummelstown, PA 17036 (717) 547-9220 www.communityderm.com (717) 260-3711 www.allaboutfaces.biz I would like to take this opportunity
NAME: PREFERRED NAME/NICKNAME: _ BIRTH DATE: SS#: MALE FEMALE ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE:
PATIENT INFORMATION NAME: PREFERRED NAME/NICKNAME: _ BIRTH DATE: SS#: MALE FEMALE ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE: EMAIL: MAY WE CONTACT YOU BY TEXT? Y / N CHECK APPROPRIATE
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival)
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival) Patient s Name First Last M.I. Nickname Address # City State Zip code Phone:
PLEASE ARRIVE TO THE CLINIC 30 MINUTES EARLY FOR YOUR APPOINTMENT
130 North Broadway Table Grove, IL 61482 Telephone: (309) 758-5070 Fax: (309) 758-5007 www.cmhospital.com Thank you for choosing Table Grove Community Medical Clinic for your Healthcare needs. We always
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
NEW PATIENT REGISTRATION
NEW PATIENT REGISTRATION Patient: Preferred Name: Last Name First Name Middle Initial Home #: Work #: Cell #: Email Address: The best way to contact me is through: Text Email Cell Home Work No preference
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
NORTHSIDE PRIMARY CARE
NORTHSIDE PRIMARY CARE Dr AAZRUM I. SYED, M.D. 11820 Northfall Lane Suite 1103 ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES **You may refuse to sign this acknowledgment** I, have received
The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in
The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in Patient Information Thank you for choosing our practice for your chiropractic needs. Please
CRYSTAL CITY FOOT AND ANKLE CARE DR RONALD LOUCKS, DPM FAX Robert Thompson Ln, Festus, MO
636-931-9600 FAX 636-933-9116 20-0994430 1316946940 Welcome/Welcome back to our office! Please fill out this paperwork COMPLETELY, each section must be completed in full, please. Even if you have been
for / / at in (Provider name) (date) (time) (location)
Welcome to our practice. We strive to make the registration process go as quickly for you as possible on the day of your appointment with for / / at in (Provider name) (date) (time) (location) In order
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
Street Address: Apt. # City State Zip. Employer Name and Address. City State Zip. Name of Spouse or Guardian. Emergency Contact Name and Phone
Patient Name Social Security Number: Date of Birth: Age: Street Address: Apt. # City State Zip Home Phone: ( ) -- Mobile Phone: ( ) -- Employer Name and Address City State Zip Business Phone ( ) -- Occupation