PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
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1 PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 -
2 NEW PATIENT MEDICAL INFORMATION Patient Name: Today s Date: Gender: Male [ ] Female [ ] Date of Birth: Age: Height: Weight: Race: o American Indian or Alaskan Native o Asian o Black or African- American o More Than One Race o Native Hawaiian o Other Pacific Islander o White o Refused to Report/Unreported Ethnicity: o Hispanic or Latino o Non- Hispanic or Latino o Refused to Report/Unreported Language: o English o Spanish o Other: Reason for Consultation (include symptoms / signs if any): Date of Onset (may approximate): Previous/Existing Medical Conditions (list): Previous Surgical Procedures (list with approximate dates): Current Medications (with dosages): Local Pharmacy: Town: Telephone Number:( ) - Mail Order Pharmacy: Telephone Number: ( ) - Medication or Environmental Allergies (list with symptoms / signs):_ Family History Please indicate any relevant family history and which family members it pertains to: Social History: Dominant Hand: o Right handed o Left handed o Ambidextrous Is the patient currently enrolled in school? If so, what grade or level? Does the patient participate in any physical activities? o Yes o No If so, what types of activities? Please describe your Current Tobacco Use?(Skip, if patient is young child)o Smoker, current status unknown o Light tobacco smoker o Heavy tobacco smoker o Current everyday smoker o Current some day smoker o Never smoker o Unknown if ever smoked I certify that the above information is accurate to the best of my knowledge: Signature X - 2 -
3 REVIEW OF SYSTEMS: Please place a check mark in the box next to any of the following symptoms or problems if you have experienced them recently or have concerns about them. If you don t understand something place a question mark? by it. Your doctor or nurse practitioner will discuss any positive responses with you. General: q Chills q Fever q Night Sweats q Significant Weight Change Skin: q Bruising q Dryness q Excessive Sweating q Hair Loss q New Lesions q Rash HEENT: q Blurred Vision q Hearing Loss q Seasonal Allergies Neck: q Neck Mass q Swollen Glands Respiratory: q Cough q Difficulty Breathing q Sleep Apnea q Wheezing Cardiovascular: q Anemia q Bleeding Tendency q High Blood Pressure q High Cholesterol q Leg Pain and/or Swelling Gastrointestinal: q Constipation q Diarrhea q Nausea q Vomiting Genitourinary: q Frequency q Incontinence q Painful Urination q Other: Musculoskeletal: q Upper Back Pain q Lower Back Pain q Joint Swelling q Other: Endocrine/Glands: q Appetite Changes q Excessive Urination q Thyroid Problems q Other: Neurological: q Fainting q Difficulty Walking q Dizziness q Headache q Loss of Consciousness q Migraines q Numbness q Weakness q Seizures q Tingling Hematology: q Anemia q Blood Clots q Easy Bruising q Easy Bleeding q Enlarged Lymph Nodes Psychiatric: q Anxiety q Depression q Easily Irritated q Memory Loss q Suicidal Thoughts None of the Above
4 NEW PATIENT DEMOGRAPHICS Patient: Name (Last, First): _ Date of Birth: Age: Home Telephone Number: ( ) - Cell Phone Number (if adult): ( ) - Home Address (Street, City, State, Zip): Address (if adult): Lives with (circle) Mother / Father / Both / Other Mother: Name (Last, First): _ Home Address (Street, City, State, Zip) (Leave blank if same as patient): Profession, Workplace Name: Work Address (if child is below 18): Father: Name (Last, First): _ Home Address (Street, City, State, Zip) (Leave blank if same as patient): Profession, Workplace Name: Work Address (if child is below 18): Other Guardian (If applicable such as foster parent, guardian grandparent, etc): Name (Last, First): Relationship: Home Address (Street, City, State, Zip) (Leave blank if same as patient): Profession, Workplace Name: Work - 4 -
5 NEW PATIENT DEMOGRAPHICS Patient Name: Today s Date: Pediatrician/Primary Care Provider: Name: Address (Street, City, State, Zip): Partners familiar with patient: Pharmacy: Town: Phone Number: Other Physician: (Specialty ) Name: Address (Street, City, State, Zip): Partners familiar with patient: Other Physician: (Specialty ) Name: Address (Street, City, State, Zip): Partners familiar with patient: INSURANCE INFORMATION ***WE MUST MAKE A COPY OF ALL INSURANCE CARDS*** PRIMARY Insurance: Full name of policy holder: Date of Birth: Policy ID Number: Group Number Employer: SECONDARY Insurance: Full name of policy holder(if different from above): Date of Birth: Policy ID Number Group Number RELEASE Your Signature here allows for the RELEASE of medical information to your insurance company and for the direct assignment of benefits to our provider X Date - 5 -
New Patient Packet. Thank you for choosing Shasta Regional Medical Group. Our office looks forward to serving you.
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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:
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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 REGISTRATION
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Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -
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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:
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
Winter Park Colon & Rectal Specialists, LLC JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 Winter Park, FL 32792
JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 DATE: PLEASE PRINT NAME: Last First MI GENDER: M F DATE OF BIRTH: AGE: SSN: _ MARITAL STATUS: Single Married Widowed Divorced Separated RACE: White Black
PATIENT UPDATE FORMS (fill out or print and use black ink)
Foothills Weight Loss Specialists Mark Colquitt, MD FACS & Jonathan Ray, MD FACS Center for Advanced Medicine Building 1819 West Clinch Ave, Suite 200 Knoxville, TN 37916 865-984-3413 office 865-212-5597
Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?
PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
Dr. Peter F. Gregory, D.P.M. Patient s Name: Date: / / Address: City State Zip Date of Birth: / / Sex: Male Female Home Phone: Cell Phone: Business Phone: Email: (Please check preferred method of contact
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,
NOTICE TO PATIENTS REGARDING PHYSICALS/WELL EXAMS
NOTICE TO PATIENTS REGARDING PHYSICALS/WELL EXAMS If you have scheduled an Annual Wellness Visit (AWV), PAP, or physical exam for today, your insurance company may call this visit preventative, yearly
We look forward to your visit and appreciate the opportunity to participate in your rheumatologic care.
Welcome to the Carolina Center for Rheumatology and Arthritis Care! The New Patient Pack gives our doctors detailed information to assess your condition and we ask that you pay particular attention when
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
DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS? CIRCLE YES OR NO ON EACH ONE
DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS? CIRCLE YES OR NO ON EACH ONE ALLERGIC: GASTROINTESTINAL: 1. FREQUENT INFECTIONS YES NO 44.PAIN IN STOMACH YES NO 2. METAL ALLERGIES YES NO 45. DIARRHEA YES NO
PATIENT INFORMATION - DO NOT LEAVE ANY PORTION BLANK.
Name: Address: PATIENT INFORMATION - DO T LEAVE ANY PORTION BLANK. PLEASE PRINT the following information. City/State/Zip: SSN: Birthdate: Gender: Language: English Spanish Other Home Ph: Work Ph: Race:
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:
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
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 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: