PEDIATRIC PATIENT INFORMATION
|
|
- Tyler Blankenship
- 5 years ago
- Views:
Transcription
1 PEDIATRIC PATIENT INFORMATION Due to new HIPPA regulations ALL information must be filled out, otherwise we will not be albe to process your claim and you will be billed for the medical services. LAST NAME: FIRST NAME: ADDRESS: CITY: STATE: ZIP: DATE OF BIRTH: / / GENDER: M F PARENT/GUARDIAN Please complete if Patient is a Minor PARENT/GUARDIAN NAME: DATE OF BIRTH: / / HOME PHONE: CELL PHONE: MAY WE LEAVE MESSAGES FOR YOU AT THESE NUMBERS? ADDRESS (If Different): CITY: STATE: ZIP: DO YOU AUTHORIZE THIS OFFICE TO DISCUSS YOUR CHILD S CARE OR TREATMENT WITH ANY PARTY OTHER THAN YOURSELF, INCLUDING FAMILY MEMBERS? IF, WITH WHOM? REFERRING PHYSICIAN NAME: PHONE NUMBER: HOW DID YOU FIND OUT ABOUT US? YELLOW PAGES INTERNET REFERRED BY PATIENT ADVERTISMENT INSURANCE REFERRED BY PHYSICIAN CONSUMER SEMINAR EMPLOYER OTHER 1
2 PATIENT INFORMATION Due to new HIPPA regulations ALL information must be filled out, otherwise we will not be albe to process your claim and you will be billed for the medical services. EMPLOYMENT EMPLOYMENT STATUS: FULL TIME PART TIME SELF-EMPLOYED RETIRED STUDENT OCCUPATION: MAY WE CONTACT YOU AT WORK: EMPLOYER: WORK PHONE: WORK ADDRESS: CITY: STATE: ZIP: INSURANCE INFORMATION PRIMARY INSURANCE CARRIER: POLICY HOLDER NAME (IF DIFFERENT THAN PATIENT) : DOB: INSURANCE THROUGH EMPLOYER: IF, EMPLOYER NAME: INSURED ID#: GROUP#: RELATIONSHIP TO PATIENT: SECONDARY INSURANCE CARRIER: _ POLICY HOLDER NAME (IF DIFFERENT THAN PATIENT) : DOB: INSURANCE THROUGH EMPLOYER: IF, EMPLOYER NAME: INSURED ID#: GROUP#: RELATIONSHIP TO PATIENT: 2
3 PATIENT INFORMATION Due to new HIPPA regulations ALL information must be filled out, otherwise we will not be albe to process your claim and you will be billed for the medical services. Authorization to Release Information and assignment of Benefits I authorize payments of medical benefits to the provider for the service rendered or to be rendered in the future without obtaining my signature on each claim submitted. I also authorize the release of any medical information necessary. I understand that I could be subject to a cancellation fee for each appointment missed where no notice is given or less than 24 hours of notice is given. I am responsible for all charges regardless of insurance coverage. If this account should be referred to a collection agency, I will be responsible for any collection and/or legal fees. I have read and understand this office policy and procedure. SIGNATURE: DATE: PARENT/GUARDIAN SIGNATURE: DATE: 3
4 Scheduling and Appointment: Arizona Balance and Hearing Aids, LLC is open from 8:00 to 4:30 Monday through Thursday, with the last appointment scheduled at 3:00. We are open on Friday from 8:30 to 12:00. Courtesy Calls: We make every effort to give a courtesy call as a reminder of scheduled appointments for the next day. Unfortunately, this is not always possible. It is the responsibility of the patient/parent/legal guardian to keep record of all upcoming appointments. In the event that a courtesy call is not made, the patient/parent/legal guardian is still responsible to keep the appointment or cancel at least 24 hours in advance. Cancellation Policy: Our audiologists want to ensure that you receive proper medical care, so it is out desire that you attend all scheduled visits. We understand that circumstances may arise prohibiting you from keeping your appointment. If you find that you are unable to keep your appointment we kindly request that you notify us at least 24 hours in advance. Failure to do so will result in a $50.00 to $75.00 charge to your account. In the event that you have had 2 missed appointments, we will have no choice but to dismiss you from our practice. Late Arrival: Please ensure that you are able to arrive at the office 15 minutes before your scheduled appointment. This will allow for out schedule to proceed smoothly. If you are late by more than 15 minutes, we will take you off the schedule and will have to accommodate you in the next available slot which will increase your wait time and sometimes require rescheduling. Insurance: In order to help you receive your maximum insurance allowable benefits, we need your assistance and understanding of our payment policy. We will require a copy of your insurance card in order to bill your office visit appropriately. We are required by law to obtain your signature for permission to release information to your insurance carrier. Our failure to obtain these updates could result in criminal and civil penalties and/or expulsion from your insurance plan. We will gladly submit fees for your covered medical services to your insurance company. However, we expect payment of all services within 60 days. It may become necessary for you to pay your account in full if your insurance company fails to pay for services within 60 days. It is your responsibility to understand your coverage and benefits, including pre-certification, referral and authorization requirements. We will, however, assist you to ensure that all plan requirements are met. X (Please Initial) Patient/Parent/Legal Guardian (Please Print) Patient/Parent/Legal Guardian Signature Date 1
5 Payment for Services: Payment for services, including co-payment and deductible amounts, are due at the time services are rendered unless payment arrangements have been approved by our billing office staff. We accept cash, checks, MasterCard and Visa. Our failure to collect these amounts is a violation of our contract with your insurance company and may result in civil or criminal penalties and/or expulsion from your insurance plan. In addition, your failure to pay the required co-amounts is a violation of your financial responsibility for coverage and we may report your refusal to pay these amounts to your insurance company. If you cannot furnish an insurance card at the time of the visit, you will be responsible for payment in full at the time of service. It is not the responsibility of our office to obtain this information for you. We will be happy to supply you with an accounting of the visit so that you may submit the information to your insurance company for reimbursement. X (Please Initial) Returned Checks will result in a $40.00 fee that will be posted to your account. Returned checks, balance older than 60 days, and failure to pay account balances as promised may be subject to external collection and additional fees, including attorney and other court fees. General: We will gladly discuss your proposed treatment and answer questions relating to your insurance. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. We must emphasize that as medical providers, our relationship is with you, not your insurance company. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. While filing of the insurance claim is a courtesy that we extend to patients, all charges are your responsibility from the date the services are rendered. X (Please Initial) We realize that temporary financial problems may affect timely payment on your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. My signature below constitutes acknowledgment and acceptance of this policy. Patient/Parent/Legal Guardian (Please Print) Patient/Parent/Legal Guardian Signature Date 2
6 PEDIATRIC CASE HISTORY Name: Age: Birth Date: EAR HISTORY Do you think your child has difficulty hearing? (Please circle one) If Yes, when did you first notice this and which ear(s)? Please circle or for the following questions: Frequent ear infections Frequent colds Ear Surgery (including tubes) Speech or language problems Family history of hearing loss BIRTH HISTORY Did your child pass their newborn hearing screen? Hospital Name: Mother s Full Name and Date of Birth: Pediatrician s Name and Telephone Number: At birth, did the baby suffer from/experience any of the following complications? (Please check all that apply) Jaundice Breathing/respiratory difficulties Cesarean birth Breech birth Premature birth Infection of baby or mother Low birth weight Low APGAR score Blue color Sucking/ swallowing difficulties MEDICAL HISTORY Please list any serious illnesses or injuries for which your child ever received treatment: Please list any current medications/ known allergies: DEVELOPMENT HISTORY Does your child s rate of development seem normal to you? (Please circle one) Has your child undergone any of the therapies listed below? (Please circle one) Speech/Language Therapy Occupational Therapy Physical Therapy Vision Therapy
Patient Information. Patient Name: Address . City State Zip. Birthdate Sex: Female Male Marital Status: Married Single Other
Patient Information Patient Name: Address Email City State Zip Birthdate Sex: Female Male Marital Status: Married Single Other Home Phone Work Phone Cell Phone Student Status: Full Time Part Time None
More informationChild s Name Date of Birth. Address. City State Zip. Father s Name Phone (home) Phone (cell) Address. City State Zip.
Client Information Child s Name Date of Birth Address City State Zip Father s Name Phone (home) Phone (cell) Address City State Zip Email Father s Employer Mother s Name Phone (home) Phone (cell) Address
More informationPatient Intake Form. How did you hear about us? (Please check one) Internet Doctor Referral Health Insurance. Friend/Patient Referral Drive- By Other
Patient Intake Form How did you hear about us? (Please check one) Internet Doctor Referral Health Insurance Friend/Patient Referral Drive- By Other If a Friend or Doctor referred you, please give us their
More informationPATIENT INFORMATION. Child s Name: DOB: Address: Phone: Zip: School: Emergency Contact: Phone: Relationship to Patient:
PATIENT INFORMATION Child s Name: DOB: Address: Phone: Zip: School: Father s Name: Occupation: Phone: (work) Email Address: Mother s Name: Occupation: Phone: (work) Email Address: DOB: Social Security
More informationPediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA Poonam Singh, M.D. * Elizabeth Sanchez Fowler, M.D. * Tonya Suffridge, M.D. * Anuradha Venkatachalam, M.D. Balbir Singh,
More informationChild s Name: Gender: M or F Last First MI. Date Of Birth: - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE. Physician Name Last First MI
PATIENT INFORMATION PATIENT INTAKE FORM DATE: PT/OT/ST Child s Name: Gender: M or F Last First MI Date Of Birth: - - SS# - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE Physician Name Last First MI Phone:
More informationBeyond Limits Audiology Newborn Case History
Beyond Limits Audiology Newborn Case History Child s Name: Date: Birthdate: Gender: Male Female Diagnosis: Parents Names: Marital Status: Birth Parents Foster Parents Adoptive Parents Guardians Parents
More informationINTERNATIONAL CRANIOFACIAL INSTITUTE
Patient Information INTERNATIONAL CRANIOFACIAL INSTITUTE Guarantor/Responsible Party Home( ) Work( ) Cell( ) Email Preferred Method of Contact of Birth Sex Marital Status Driver's License # State Student:
More informationPLEASE PRINT & FILL OUT COMPLETELY PATIENT/PARENT INFORMATION ADDRESS:
2150 S. Eastern Avenue 7180 Cascade Valley Ct. #180 Las Vegas, Nevada 89104 Las Vegas, Nevada 89128 Phone (702) 641-2150 Phone (702) 641-2150 Fax (702) 641-8667 Fax (702) 228-1043 PLEASE PRINT & FILL OUT
More information2460 India Hook Road, Suite 106 Rock Hill, SC Tel: (803) Fax: (803)
2460 India Hook Road, Suite 106 Rock Hill, SC 29732 E-mail: drj@rockhillkids.com Tel: (803) 327-3327 Fax: (803) 334-3474 Welcome to our practice! Please carefully complete this form so that we may better
More information8) Therapeutic drug monitoring: medication levels in the blood. 9) Any additional valid measurements of the child over the last 3 years
Intake Checklist We know you are excited to have your child diagnosed by our world-class diagnostic system. We are too! For a smooth and productive first visit, please bring the following documents with
More informationWelcome! 7000 W. Plano Parkway Plano, TX Please remember to bring: New Patient Paperwork. Current Insurance Card
7000 W. Plano Parkway Plano, TX 75093 SW corner of Plano Pkwy & Marsh Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of
More informationInnovative Hearing Services, Inc.
Patient Information Innovative Hearing Services, Inc. Patient s Name Address City State Zip Home Phone Work Phone Email Address Soc Sec # Date of Birth Sex: Female Male Marital Status: Married Single Other
More informationTherapy Group of Tucson, PLLC DEMOGRAPHICS PRIMARY INSURANCE INFORMATION SECONDARY INSURANCE INFORMATION N. Rosemont Drive, Ste.
Therapy Group of Tucson, PLLC 2260 N. Rosemont Drive, Ste. 100 Tucson AZ 85712 Phone: (520) 232-2021 Fax: (520) 232-2553 DEMOGRAPHICS Name: Age: Sex: male female Social Security #: - - Date of Birth: Street
More informationWelcome! Warren Parkway Suite 306 Frisco, TX PlastiksForKids.com. Please remember to bring: New Patient Paperwork
Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. All appointments are on Monday afternoons. Dr. Stiles operates at the Pediatric Surgery Center. Plastiks
More informationLAS VEGAS ENDOCRINOLOGY
Today s Date: Primary Care Provider: Patient Information Last Name: First Name: Date of Birth: Sex: M F Social Security #: Street Address: City: State: Zip: Occupation: Employer: Home Phone: Cell Phone:
More informationAllergies 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
More informationJUST US KIDS PEDIATRICS NEWBORN HISTORY FORM
JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM DATE: PATIENT NAME: D.O.B BIRTH HISTORY WAS YOUR BABY FULL TERM? PRE-TERM? ADOPTED? IF PRE-TERM, HOW MANY WEEKS? IF ADOPTED, AT WHAT AGE? TYPE OF DELIVERY:
More informationPEDIATRIC REGISTRATION FORM
PEDIATRIC REGISTRATION FORM **Today s Date: PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: *First Name: Middle Initial: *Address: City: State: Zip: *Sex: *Date of Birth: Age:
More informationJUST US KIDS PEDIATRICS NEWBORN HISTORY FORM
JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM DATE: PATIENT NAME: D.O.B BIRTH HISTORY WAS YOUR BABY FULL TERM? PRE-TERM? ADOPTED? IF PRE-TERM, HOW MANY WEEKS? IF ADOPTED, AT WHAT AGE? TYPE OF DELIVERY:
More informationPatient Medical History Form
Please complete the following forms to help expedite your visit! Preferred pharmacy location: Patient Medical History Form Patient's Name: DOB: Referring Doctor: What are your concerns for today's visit?
More informationNew Patient Paperwork Current Insurance Card Valid Driver s License It is also important
Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of our Frisco practice that focuses on Pediatric Plastic Surgery. All appointments
More informationTree House Pediatrics, PLLC
Tree House Pediatrics, PLLC Office Policies Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policies allows for a good flow of communication
More informationThe Speech Pathology Learning Center
The Speech Pathology Learning Center 8514 W. Gage Blvd Kennewick, WA 99336 Tel: (509)73LOGIC {735-6422} Fax: (509)735-2426 New Patient Packet Prior to scheduling an appointment for an evaluation, we require
More informationFamily address preferred for patient portal access:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone Number: Siblings: Name Sex DOB
More informationDear Parent, Thank you for choosing Sunset Pediatrics as your child s medical home!
Dear Parent, Thank you for choosing Sunset Pediatrics as your child s medical home! We are proud to follow the principles of being a Patient Centered Primary Care Home. What this means is that we strive
More informationTEXAS ASSOCIATION OF PEDIATRIC NEUROLOGY, P.A. Jerry J. Tomasovic, M.D.
Jerry J. Tomasovic, M.D. PATIENT NAME D.O.B. Who referred you today? What are the concerns that brought you here today? What specific questions do you have today? Please list present medication and dosage:
More informationChild Health and Dental History Form
Child Health and Dental History Form Child's Name Last First Middle Nickname/Preferred Name Birthday / / Address: Street City State Zip Gender: Male Female Parent Info (please circle): Mother Father Guardian
More informationPATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION RECORD (Please Print or Write Legibly) DATE ACCT # PATIENT INFORMATION NAME First Middle Init. Last MAILING ADDRESS CITY STATE ZIP SEX RACE Ethnicity: q hispanic/latino q Not Hispanic/Latino
More informationPatient Information Form
Patient Information Form Name Birthdate Social Security Number Age Address Occupation Phone Number Alt. Phone Number Email Emergency Contact & Phone Number How Did You Hear About Us What Are You Coming
More informationCenter for Speech & Language Pathology, LLC
Center for Speech & Language Pathology, LLC 600 Saint Clair Ave. SW, Building 6 (256) 533-3314 CenterForSpeech.net CSL Adult Intake Form Today's : Name of person completing this form: Relationship to client:
More informationOffice and Financial Policies
Office and Financial Policies Thank you for reviewing the following office and financial policies. We commit to put forward our best efforts to provide you with the most up to date, skilled, and compassionate
More informationPatient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
More informationBeyond Limits Audiology School Age Case History
Beyond Limits Audiology School Age Case History Child s Name: Date: Birthdate: Age: Gender: Male Female Diagnosis: Parents Names: Marital Status: Birth Parents Foster Parents Adoptive Parents Guardians
More informationLast Name: First Name: MI: Preferred Name: Name as on Insurance: SSN: - - (*Required for insurance claims) Address: City: State: Zip Code:
1 of 7 Chart # 832 Quince Orchard Blvd 220 Main Street 10339 Kensington Parkway Gaithersburg, MD 20878 Gaithersburg, MD 20878 Kensington, MD 20895 (301) 948-0058 (301) 519-3232 (301) 949-2280 Mission Statement
More informationWe are limited, not by our abilities, but by our vision.
We are limited, not by our abilities, but by our vision. WELCOME Thank you for choosing Advanced Eye Care Center as your eye healthcare provider! On behalf of Dr. Lawrence Shafron, Dr. Rodgers Eckhart,
More informationGentle 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
More informationPast Medical History
Past Medical History Patient Name Age: Sex: M or F Allergies:_ of Birth Current Medicines: If Newborn: Was baby born in a Hospital: Y N If Yes what Hospital: Medical History BIRTH HISTORY (Please list
More informationMARTIN S PEDIATRICS AND FAMILY CARE: ADULT CHECK IN FORM
MARTIN S PEDIATRICS AND FAMILY CARE: ADULT CHECK IN FORM NAME DOB: Food/Drug Allergies: Current Medications: Reason for Today s Appointment: PAST MEDICAL HISTORY Please check if you have any of the following:
More informationYvonne Knapp, MS, CCC/SLP Adult Case History Form GENERAL INFORMATION. Address: City: State: Zip Code: Telephone: Occupation: Family Physician:
GENERAL INFORMATION Name: Date of Birth: Address: City: State: Zip Code: Telephone: Occupation: Family Physician: Address: Single Widowed Divorced Spouse s Name: Referred by: Address: Diagnosis: Reason
More informationNeurology Center of Wichita
Neurology Center of Wichita Dr. Subhash Shah, M.D and Kathryn Welch, PA-C 220 S. Hillside Wichita, KS 67211 Phone: 316-686-6866 Fax: 316-686-9797-website: www.pedsbrain.com In order for the doctor to better
More informationTEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: _ Primary Care Physician: _
TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: Primary Care Physician: Patient s LEGAL Last name: First: Middle Initial: Patient date
More informationIdentifying and Family Information Child s Name: Birthdate: M F Father s Name: Daytime Phone: Address: Cell Phone:
Speech-Language-Hearing Case History Form Identifying and Family Information Child s Name: Birthdate: M F Father s Name: Daytime Phone: Address: Cell Phone: Email: Mother s Name: Daytime Phone: Address:
More informationIf you are already an established patient of either Dr. Aroesty or Ms. Corrice, you do not have to reregister or fill out any additional paperwork.
To Our New Patient: Our staff would like to take this opportunity to welcome you to Garden State Snoring Solutions, LLC. It is our goal to make your visit with us as pleasant and comfortable as possible.
More informationMacInnis Dermatology New Patient Registration Form
MacInnis Dermatology New Patient Registration Form Please print and answer all questions in full Date Patient Information (please complete using your name as listed on your insurance card) Patient First
More informationPermission Letter. Patient Name(s):
Permission Letter Patient Name(s): If someone other than the parent or legal guardian may bring your child (ren), please list their name(s) below. They must be 18 years of age and have a photo i.d. We
More informationNew Patient Registration Form. New Patient Update Date: / /
New Patient Registration Form New Patient Update Date: / / Children s Names Gender Birthdate Race* Ethnicity *Race = White American, Native American, Alaska Native, Asian American, Black or African American,
More information*PLEASE PROVIDE COPIES OF YOUR DENTAL ID CARD AND DRIVERS LICENSE*
DR. MILES MAZZAWI DR. ANTHEA DREW MAZZAWI DR. NIRALI PROCTER 205 Waleska Rd. Suite 2-B Canton, GA 30114 (770) 479-1717 Today s Date: / / We are so pleased to welcome you and your child to our practice!
More informationREGISTRATION FORM. Today s Date: / / Previous PMD: PATIENT INFORMATION NAME: DOB: / / GENDER: NAME: DOB: / / GENDER: NAME: DOB: / / GENDER:
REGISTRATION FORM Today s : / / Previous PMD: PATIENT INFORMATION NAME: DOB: / / GENDER: NAME: DOB: / / GENDER: NAME: DOB: / / GENDER: NAME: DOB: / / GENDER: FAMILY / CONTACT INFORMATION PARENT/LEGAL GUARDIAN
More informationCamden County Foot and Ankle Associates
Camden County Foot and Ankle Associates Jennifer M. Berlin, D.P.M. 17 White Horse Pike Suite 10A Haddon Heights, NJ 08035 Phone: (856) 546-8989 Fax: (856) 546-8905 Kenya A. Wiltsie, D.P.M. Please fill
More informationPATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
More informationWelcome to Pediatric Therapy Center, PC!
Welcome to Pediatric Therapy Center, PC! We appreciate the opportunity to work with you and your child. Please read through and complete all paperwork before your arrival. We ask that you please arrive
More informationPATIENT REGISTRATION
First Name Middle Name Last Name Preferred Name PATIENT REGISTRATION Patient Information Byron C. Cotton, M.D., FAAP Gayla Woodson, MSN, CPNP First choice for infants thru young adult! First Patient Second
More informationTHREE-FIVE YEAR HEALTH QUESTIONNAIRE. Pharmacy Name/City/Street:
THREE-FIVE YEAR HEALTH QUESTIONNAIRE Patient s Name Age DOB: Person filling out form Pharmacy Name/City/Street: (Please list a preferred pharmacy even if no medications are needed as we will add it to
More informationSILVERDALE 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
More informationIDENTIFYING INFORMATION
IDENTIFYING INFORMATION Child s Name: Date of Birth: Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Mother s Name: Father s Name: Email Address: Siblings: Languages Spoken at Home: Caretaker
More informationPatient Information. Name Birthdate Age. Single Married Separated Divorced Widowed. Cell Phone ( )
Patient Information Name Birthdate Age Male Female Single Married Separated Divorced Widowed Primary Phone ( ) Secondary Phone ( ) Cell Phone ( ) Email Appoint Reminder Message Type (Please circled preferred)
More informationCHILD S REGISTRATION & HISTORY
SIMON P. MORRIS, D.D.S. MAI DINH D.D.S., M.S. CHILD S REGISTRATION & HISTORY Child s name FIRST MIDDLE LAST Nickname Date of birth Age Male Female Child s interests Pets Other children in family who are
More informationAll About Kids Pediatric Dentistry
Dr. Courtney Wilson & Dr. Melanie Nesbitt Patient Registration Date: Patient s Name Nickname Birth date Age Sex Patient s Address Contact Phone # street city state zip Father s Name DOB Mother s Name DOB
More informationFirst Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:
Patient Information First Name: Middle Name: Last Name: Date of Birth: Gender: M F Preferred Name: Address: City: State: Zip: Contact Information Mother s First & Last Name: Mother s Address (If different
More informationHAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN (317)
HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN 46037 (317)-284-8888 Patient Name: Date of Birth: / / First MI Last SS#: Address: City: State: Zip Code: Cell Phone: ( ) - Home Phone:
More informationPatient Information. Responsible Party. Notify in case of emergency?
We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you. We look forward
More informationADDRESS: APT#: CITY: ZIP: IF ANOTHR PHYSICIAN, WHO?
PEDIATRIC PATIENT INFORMATION SHEET ENT & AUDIOLOGY CENTER OF SOUTHLAKE PHONE: (817) 416-9731 FAX: (817) 416-9751 PATIENT NAME (LAST, FIRST, MIDDLE) AGE: SEX: ADDRESS: APT#: CITY: ZIP: PATIENT HOME PHONE:
More informationPatient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone: Address: Emergency Contact Name and Phone Number:
Patient Registration Patient Name: DOB: Sex: Male/Female Primary Address: Home Phone: Mobile Phone: Email Address: Emergency Contact Name and Phone Number: Primary Language: Race(s): (Circle all that applies)
More informationNew Patient Registration
New Patient Registration 900 Carillon Parkway, Suite 404 Saint Petersburg, Florida 33716 Ph: 727-572-1333 Fax: 727-572-1331 www.spencerdermatology.com Today s : / / Name: (First) (Middle) (Last) (Suffix)
More informationELYSE S. RAFAL, F.A.A.D.
ELYSE S. RAFAL, F.A.A.D. Welcome to our practice. Thank you for placing your trust in us. We look forward to serving you with quality and compassionate care. Patient Information Today s : First Name: M.I.
More informationMadison Dentistry 424 Madison Avenue 15th Floor New York, NY (212) Patient Information. Health Information
Madison Dentistry 424 Madison Avenue 15th Floor (212)753-7400 Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Patient Information Birth Date: Family Status: Chart #: FOR OFFICE
More informationINITIAL INTAKE FORM. Date Patient Information: M F - - / / / Patient s Name (last, first, middle) Sex Social Security Number Age Yrs/Months DOB
INITIAL INTAKE FORM Date Patient Information: Referring Physician Patient s Primary Care Physician M F - - / / / Patient s Name (last, first, middle) Sex Social Security Number Age Yrs/Months DOB ( ) -
More informationDILIP TAPADIYA, M.D. INC. Demographic Form
Demographic Form 1. PATIENT Name Soc Sec No: City: State: Zip: Birthdate: Driver s License No: Sex: Home Phone: ( ) Cell Phone: ( ) Marital Status: Occupation: 2. RESPONSIBLE PARTY Name: Soc Sec No: City:
More informationPatient Information. Health Information
PLEASE COMPLETE PRIOR TO YOUR APPOINTMENT. Return Via: Email:crosspatientcoordinator@verizon.net Fax: 301-662-4945 OR Bring to your appointment Patient Information Patient Name: Date: Last First MI Preferred
More informationFAMILY HISTORY CHILD/CHILDREN S NAME:
FAMILY HISTORY CHILD/CHILDREN S NAME: FAMILY HISTORY (THINK IN TERMS OF THE CHILD S SIBLINGS, PARENTS, GRANDPARENTS, AUNTS, UNCLES AND FIRST COUSINS): ANY ALLERGIES, HAY FEVER, ASTHMA OR ECZEMA? WHO? ANY
More informationMorris Medical Center, P.A.
Thank you for choosing our practice to assist in your healthcare needs. We appreciate the confidence you and your personal physician have placed in us. Please read the following instructions and information
More informationTILAK PEDIATRICS Patient Information Form For all Patients 18 years of Age and Older
Patient Information Form For all Patients 18 years of Age and Older Patient s Information Name: DOB: / / Male Female RACE African-American American Indian/Alaska Native Asian Caucasian Native Hawaiian/Pacific
More informationKinsler Psychology Help when life hurts
1 ADULT INTAKE HISTORY Patient Name Date Age Birthdate Birthplace Gender Male/Female Address City State Zip Social Security# Home Phone Cell Phone Work Phone Occupation: Employer: Name and number of emergency
More informationWhom May We Thank for Referring You? Primary Care Physician. Insured/Responsible Party. Patient Information. Patient s Spouse/Guardian
Whom May We Thank for Referring You? Name: Other: Newspaper Radio TV Seminar Staff Yellow Pages Other Primary Care Physician Name: Address: Phone: Insured/Responsible Party Patient Information Name: Address;
More informationPatient Registration
Patient Registration First Name: Middle Initial: Last Name: Address: City: State / Zip: Responsible Party (for patients under 18): Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security Number:
More informationPATIENT INFORMATION ***All Requested MUST be filled out ****
Child, Adolescent, Adult And Family Psychology Alexander T. Gimon, PhD, PA. 10225 Ulmerton Rd Ste 12B Largo, FL 33771 Phone: 727-584-1551 3115 Citrus Tower Blvd., Clermont FL 34711 Phone: 352-241-8540
More informationPATIENT INFORMATION. Name of child Date of Birth Age Sex Last First Middle Preferred Name (Nickname) HomeAddress Street City State Zip
Welcome to! We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out these forms as completely as you can. If you have questions we will be glad to help you.
More informationHolistic Speech & Language Phone: (206) Fax: (206)
Client Intake Form Demographic Information Last Name: First Name: of Birth: Sex: Diagnosis (if known): Parent/Guardian Name(s): Home Address: Parent #1 Phone: Parent #2 Phone: Parent #1 Email: Parent #2
More informationPlease list all current medications and supplements that you are taking:
PATIENT HEALTH AND MEDICAL HISTORY Today s Date: Chief Complaint for Today s Visit: Was this injury gradual or sudden onset? Date of sudden onset: Please explain: Do you have a history of present symptoms?
More informationWELCOME TO FETZER FAMILY CHIROPRACTIC
WELCOME TO FETZER FAMILY CHIROPRACTIC Patient Information Thank you for choosing Fetzer Family Chiropractic for your health care needs. Please complete this form in ink. If you have any questions or concerns,
More informationCenter of Excellence in Spinal Care. Patient Information. If Patient is a minor Guarantor Name: If Patient is a minor Guarantor Social Security #:
Center of Excellence in Spinal Care Patient Information Patient Name: Patient Date of Birth: Today s Date: Current Age: Sex (Circle One) Male Female Patient Social Security Number: If Patient is a minor
More informationPatients who are running 20 minutes late for his/her scheduled appointment will be rescheduled to the next available appointment/ day.
Orthotics/ Durable Medical Equipment Policy H2T is NEVER able to guarantee payment by medical insurance carriers for Orthotics and/or Durable Medical Equipment. H2T will bill your medical insurance as
More informationADULT PATIENT REGISTRATION
PATIENT NAME: (LAST) (FIRST) (M) CELL: ( ) HOME: ( ) PERSONAL E-MAIL: (FOR PATIENT PORTAL) DATE OF BIRTH: / / AGE: GENDER: MALE FEMALE SOCIAL SECURITY: - - MARITIAL STATUS: SINGLE MARRIED WIDOW(ER) OTHER
More informationNew Patient Information - Dr. Marc Edelstein
Marc A. Edelstein M.D., FACP, FACG Internal Medicine and Gastroenterology Gastroenterology, Hepatology, and Nutrition Susan P. Edelstein M.D., FAAP Pediatrics and Pediatric Gastroenterology Pediatric Gastroenterology,
More informationTrinity Family Physicians
Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor
More informationPlease print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
More informationINFANT / PRESCHOOLER For Patients Infant through Pre-K
INFANT / PRESCHOOLER For Patients Infant through Pre-K Judson Family Vision Care Amanda Judson, OD, MS, FCOVD Phone: 812-232-1000 Fax: 812-232-1007 Date of Visit Patient Name (Last, First, MI) Preferred
More informationHARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION
HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION Thank you for choosing our office. In order to serve you properly, we will need the following information. PLEASE PRINT: Name: Date: (Parents/caregivers):
More informationWho to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -
4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)
More informationPatient Safety and Privacy. Appointment Policy
Patient Safety and Privacy For your comfort one adult is welcome, but not required to accompany your child to the treatment areas. We do encourage self independence to help promote the growth and development
More informationNew Leaf Physical and Massage Therapy LLC 1 of 5 HEALTH INTAKE FORM. Name Date of Birth
New Leaf Physical and Massage Therapy LLC 1 of 5 HEALTH INTAKE FORM Please fill out form entirely and bring it with you to your first office visit. Name Date of Birth A. Reason for Visit Reasons for your
More informationLong Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.
Today s Date Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.H NAME OF PATIENT (CHILD) DOB SSN of child SEX
More informationDate How did you hear about Shine? P A T I E NT I N F O R M A T I O N
How did you hear about Shine? P A T I E NT I N F O R M A T I O N 1. Patient's Name of Birth / / Gender: Male Female 2. Patient's Name of Birth / / Gender: Male Female 3. Patient's Name of Birth / / Gender:
More informationName. Name. Name Employer Occupation Relationship to patient Work Phone Ext. # DOB Soc. Sec. # Home Phone Cell Phone Address
405 S. Granite Ave. PO Box 959 Granite Falls, WA 98252 tel (360) 691-7793 fax (360) 691-5577 www.cervendentistry.com To help us better serve the needs of your child and meet his/her dental healthcare needs,
More informationPATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very
More informationPatient Information. Insurance Information
Patient Information Patient s Name: SSN: Sex: Male Female of Birth: Address: Street City State Zip Code Mother s Name: Age: Marital Status: Address: Street City State Zip Code Phone#: Cell #: Work #: Occupation:
More informationA SAMPLE FINANCIAL POLICY SHEET
A SAMPLE FINANCIAL POLICY SHEET Our Practice Financial Policy In order to reduce confusion and misunderstanding between our patients and the practice we have adopted the following financial policy. If
More informationIs this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment
PATIENT HEALTH INFORMATION The following information is requested to enable us to give the most consideration to your time and feelings. It is our sincere desire to give personal attention to each of our
More informationPatient 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: (
More information