Demographics. Last Name First M.I. Social Security Number
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1 Demographics Patient Information Last Name First M.I. Social Security Number Date of Birth Race Marital Status Single Married Divorced Widowed Other Street Address Apt # address City State Zip Home Number Employer Occupation Mobile Number Work Number Do you speak English? Yes No If no, list language: Please Read: There may be times when we need to leave you a phone message containing personal information at the numbers provided above. Please check the numbers where it is permissible for us to leave a message. Home Mobile Work Other If there is anyone besides you we are authorized to speak with, please list below: or N/A: Name Relationship Phone # s Emergency Contact Name Relationship to Patient Home Number Referring Physician Referring Physician Name Mobile Number Work Number Street Address Suite # City State Zip Phone Number Page 1 of 4
2 Patient Name: Jeffrey Angel, M.D. A. Gordon Fry III, M.D. Craig Kalter, M.D. Walter Morales, M.D. Edgard Ramos-Santos, M.D. Chris Sloan, M.D. Insurance Primary Insurance Information Are you the Policy Holder? Yes No Primary Insurance Company Phone Number Policy # Group # Address City State Zip Code Policy Holder Name (If not the patient) Relationship to Patient Date of Birth Policy Holder Employer Secondary Insurance Information (If Any) Are you the Policy Holder? Yes No Secondary Insurance Company Phone Number Policy # Group # Address City State Zip Code Policy Holder Name (If not the patient) Relationship to Patient Date of Birth Policy Holder Employer Please list your mother s maiden name to be used as a password for security purposes: Page 2 of 4
3 FINANCIAL ARRANGEMENTS AND MEDICAL INSURANCE We are committed to providing you with the best possible care. If you have had a change in insurance, we are anxious to help you receive your maximum allowable benefits. If you have had a change in insurance, please inform our office staff immediately as this could result in rejection of your claims. In order to expedite the filing of your insurance and provide you with the best possible care, we need your assistance and understanding of our payment policy. We file your insurance as a courtesy. Co-pays, deductible, and co-insurance payments are due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, MasterCard or Visa. Returned checks and balances older than 30 days will be subject to additional collection fees and a rebill fee of $ All charges are your responsibility from the date the services are rendered. Not all services are covered benefit in all contracts. If expenses are not covered for any reason, you are financially responsible for any unpaid balance. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in management of your account. When an appointment is made in our offices, a specific time is reserved for you to see the doctor. Missed appointments result in a loss of valuable time that could be spent with another high-risk patient in need of treatment and they are very costly to our office. For this reason, if you fail to keep an office visit you will be charged a fee for a missed appointment. If an appointment does need to be cancelled or rescheduled for any reason, please notify our office at least 24 hours in advance of the appointed time and no missed appointment fee will be charged. Thank you for your anticipated cooperation. I understand that I am responsible for payment of my account regardless of the status of an insurance claim and agree to pay for services or treatment rendered to me. If Florida Perinatal Associates is forced to take action for collection of any balance owed by me, either by lawsuit or otherwise, I agree to pay collection costs, including a reasonable attorney s fee and applicable rebill fees. I authorize and request my insurance company to pay Florida Perinatal Associates to provide my medical treatment and care as necessary or advisable. I hereby authorize the office of Florida Perinatal Associates to release any information to my insurance company or another physician, including the diagnosis and treatment or examination rendered to me while under their care. Signature of Patient/Insured Date Page 3 of 4
4 Please Note the Location You Will Be Visiting Main Location: Tampa Bruce B. Downs Blvd. Suite 250 Tampa, FL (813) Riverview Location S. US Hwy 301 Riverview, FL (813) Clearwater Location 2963 Gulf to Bay Blvd Suite 210 Clearwater, FL (727) Sarasota Location 5741 Bee Ridge Rd. Suite 540 Sarasota, FL (813) Lakeland Location 808 E. Main Street Lakeland, FL (863) Page 4 of 4 Page 4 of 4
5 IMPORTANT INFORMATION REGARDING ULTRASOUND EXAMINATION What is Ultrasound? Ultrasound uses the same principle as sonar. Sound waves from the ultrasound probe (far beyond the range of human hearing) bounce off of the uterus, placenta and baby, making echoes which a computer converts into detailed images. In essence, an ultrasound exam is a series of pictures of the baby and organs in the mother s pelvis. Is Ultrasound safe? There has been extensive evaluation of the safety of diagnostic ultrasound. There is no documented evidence that diagnostic ultrasound causes harm to either the mother or the baby when ordinary power and frequency is used. Ultrasound exams done in our facility are done using the lowest power level that can reasonably achieve a meaningful image. Does a normal Ultrasound prove that my baby will have no abnormalities? Ultrasound examination can detect many abnormalities, but some abnormalities are not detectable by ultrasound. The exam gives information about the size and shape of the baby and the baby s organs but does not give complete information about the function of the baby s organs or tell us that the baby is completely healthy. Abnormalities of brain function such as mental retardation cannot be detected by ultrasound. Additionally, there are many conditions that evolve over time, appearing normal at the time of the ultrasound exam but become apparent later in the pregnancy. You should realize that even with a complete ultrasound exam, we may be unable to find existing fetal abnormalities or those abnormalities that can appear later in the pregnancy or after birth. Thus, although ultrasound examination is a very helpful diagnostic tool, it should not be considered absolute proof that the baby is normal. Can Ultrasound determine if there are chromosomal abnormalities? Findings on an ultrasound exam can be an indicator of potential chromosomal abnormalities but are not definitive. Currently, the only way to assess the baby s chromosomes with certainty is to actually obtain a sample of the baby s cells by amniocentesis, chorionic villus sampling or fetal blood sampling. Some pregnancies are at increased risk for fetal chromosome abnormalities, either because of the mother s age, because of results of blood screening test, or because of findings on the ultrasound exam. It is important to realize that an ultrasound exam cannot tell for certain whether the baby s chromosome count is normal or abnormal. A normal ultrasound examination does not guarantee that the chromosomes are normal. If you have any questions concerning ultrasound, please do not hesitate to ask the ultrasound technologist, perinatologist or your doctor. You are requested to sign this document before your ultrasound examination to acknowledge that you have read and understood the information on this form and have had the opportunity to ask questions. Patient/Guardian signature Printed Name Date Date of Birth
6 NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGMENT FORM Our Notice of Privacy Practices ( Notice ) provides information about: 1) the privacy rights of our patients; and 2) how we may use and disclose protected health information about our patients Federal regulation requires that we give our patients or their authorized representatives our Notice before signing this acknowledgment. If you have any questions about your rights or our privacy practices, please send an electronic message ( ) to privacy_officer@pediatrix.com or a letter to: Privacy Officer Pediatrix Medical Group, Inc Concord Terrace Sunrise, FL By signing this form, you are only acknowledging that you have been provided our Notice. Signature of Patient or Authorized Representative Date Print Name of Patient Print Name of Authorized Representative
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OFFICE PHILOSOPHY. Name: Date:
Jaime Rodriguez, M.D., F.A.C.O.G. OFFICE PHILOSOPHY As a Perinatal Specialist, We feel it is extremely important to spend as much time as necessary with each patient to fully address you and your baby
INSURANCE INFORMATION
PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:
MacInnis 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
PATIENT INFORMATION Patient Name: Last First Middle Initial. Address. Street or P.O. Box City, State Zip
PATIENT INFORMATION - 2018 Patient Name: Last First Middle Initial Address: Street or P.O. Box City, State Zip of Birth: / / Race: Gender: Male Female Social Security #: Marital Status: Single Married
Morris 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
PATIENT 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
Please 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
Willow Bend OB/GYN Obstetrics, Gynecology & Infertility
Dear Patient, Welcome to our medical office. We look forward to meeting you soon. In order to provide you with the best possible care, please complete our registration forms prior to your first visit and
Trinity 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
MasterCare Physical Therapy, Inc.
Patient Financial Responsibility To all of our Patients: We will, as a courtesy, file your insurance claims for you. Please be advised that it is solely your responsibility to know and to understand your
PATIENT REGISTRATION FORMS PLEASE PROVIDE INSURANCE CARD(S) & DRIVERS LICENCE TO RECEPTIONIST FOR COPYING
PATIENT REGISTRATION FORMS PLEASE PROVIDE INSURANCE CARD(S) & DRIVERS LICENCE TO RECEPTIONIST FOR COPYING Registered PATIENT INFORMATION Updated Name: DOB: Age First MI last Home Address City: State: ZIP
PULMONARY AND CRITICAL CARE SPECIALISTS 160 Kingsley Lane, Suite 103 Norfolk, VA Phone: Fax:
PATIENT INFORMATION Address: PULMONARY AND CRITICAL CARE SPECIALISTS 160 Kingsley Lane, Suite 103 Norfolk, VA 23505 Phone: 757-889-6677 Fax: 757-889-6652 PLEASE PRINT Today s Date: City: State: Zip: Age:
Tree 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
PATIENT INFORMATION EMERGENCY CONTACT
Phone (614) 682-5095 Fax: (614) 891-6533 www.ohioplasticsurgeryspecialists.com PATIENT INFORMATION Name Birth Date Age (First, Middle Initial, Last) Address City State Zip Home Phone ( ) Work Phone ( )
Please 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
PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Patient Last Name: First Name: MI: Address: State: Zip: Circle contact preference: Home Phone: ( ) Business: ( ) Cell: ( ) Email: Social Security #: Date of Birth: Age: Race:
Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:
Patient Name: HIPPA PATIENT ACKNOWLEDMENT (Must be filled out by a parent/guardian if the patient is under the age of 18) We are required by law to maintain the privacy of protected health information
Who 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)
Anoop K. Reddy, M.D., P.A. Name: Date of Birth: Date: Do you have any history of bleeding problems? I.E. Hemophilia. DYes ono If yes please explain
Anoop K. Reddy, M.D., P.A. Name: Date of Birth: Date: -------------- ------------- ------------ II EMGINCV QUESTIONNAIRE Who is the referring doctor? What is the reason you are having the test? II Are
Patient Name: M F LAST FIRST MI. Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( )
Ahwatukee Family Medical Center Patient Information Date: Patient Name: M F LAST FIRST MI Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) EMAIL: Date of Birth: / / SS# Marital Status:
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION DATE Chart # PATIENT NAME AGE DATE OF BIRTH MALE FEMALE PREFFERED LANGUAGE RACE/ETHNICITY SINGLE, MARRIED, DIVORCED, SEPARATED,WIDOWED
Welcome to our Practice
Welcome to our Practice First, let us thank you for putting your trust in Georgia Eye Partners and our team. Our goal in providing this packet of information is to make the process as easy as possible
Felix Linetsky, M.D. 611 Druid Road East, Suite 303 ~ Clearwater, Florida ~ (727) ~ Fax (727)
New Patient Information Form Patient Name: Today s Date: / / Is your problem related to: Job Injury (date) Car Accident (date) Other (date) Address: City: State: Zip: Date of Birth: / / Age: Social Security
PATIENT REGISTRATION INFORMATION FOR MINORS
Today s Date: / / 620 Dr. Calvin Jones Highway, Suite 212 Please fill out and sign all registration paperwork attached. This will help us better serve you during your time at our clinic. PATIENT REGISTRATION
Stonebridge Adult Medicine, P.A. Registration Form (Please Print)
Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female
70 Hatfield Lane Goshen, New York SSN: First Name: MI: Last Name: Employment: Employed Unemployed Retired Employer: Employer Address:
70 Hatfield Lane Goshen, New York 10924 SSN: First Name: MI: Last Name: Prefix (Ms., Mr.,) Sex: M F DOB: Marital Status: Single Married Divorced Widowed Spouse Name: Employment: Employed Unemployed Retired
Family 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
PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP
PATIENT INFORMATION PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) E-MAIL
Today s date: PATIENT INFORMATION. Address:
Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Please send appointment reminders to: Mobile phone #: Email Address: Mr. Mrs. Registration and Medical History Marital status Single
COREY M. NOTIS, M.D., P.A.
COREY M. NOTIS, M.D., P.A. Registration Form Last Name: First Name Address: City: State: Zip Code: Home Phone: Work Phone Cell Phone: Date of Birth: Social Security # Emergency Contact Name: Phone #: Occupation:
Street Address City State Zip Patient Information. Cell Phone ( ) Preferred
Name (Last, First, MI) Email address Street Address City State Zip Patient Information Emergency Contact Home Phone Cell Phone Work Phone SSN Date of Birth Gender Male Female Employer Retired Disabled
PATIENT REGISTRATION INFORMATION Initial
PATIENT REGISTRATION INFORMATION Date Initial PATIENT S PERSONAL INFORMATION Please complete both sides of this form. Marital Status: Single Married Divorced Widowed Male Female Name: ( ) last name first
Please list any doctors you would like us to coordinate with for your medical care: Primary Care Doctor: Other Doctor:
D E R M A T O L O G Y D E R M A T O P A T H O L O G Y M O H S M I C R O G R A P H I C S U R G E R Y P L A S T I C S U R G E R Y Patient Information: Patient Name: Date of Birth: Sex: Marital Status: Mailing
ADULT 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
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
Policies and information:
Policies and information: Basic Policies: Please be on time for your appointments. If you are late for your scheduled appointment, there is a chance that you will be rescheduled. We require at least 24
Patient Welcome Form!
Arthritis and Rheumatology Clinical Center of Northern Virginia, PLLC 8130 Boone Blvd suite 340 Vienna VA 22182 Mahsa Tehrani MD 703-734-2222 Mahnaz Momeni MD Patient Welcome Form Dear new patient, Welcome
PATIENT 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
Patient Information. Parent or Responsible Party. Patient Authorization and Financial Responsibility
Patient Information Name Last First M.I. Mailing Address Street Apt# City State Zip HomePhone WorkPhone CellPhone Email Date of Birth / / Age Sex Marital Status Parent or Responsible Party Name Last First
New Wave Internal Medicine Clinic
Amber D. Colville, M.D. *Lydia Latour, M.D., * Ashleigh Teates NP-C Dear Patient, Thank you for your interest in becoming a new patient at New Wave Internal Medicine. Please fill out the enclosed paperwork
you like listed as your primary
Patient Information Southlake Chiropractic welcomes you to our office. We strive to provide the best possible chiropractic care. Dr. Devos will conduct a thorough history and physical exam to decide how
GAINESVILLE PHYSICAL THERAPY NEW PATIENT REGISTRATION HOW DID YOU HEAR ABOUT OUR CLINIC? PATIENT INFORMATION
GAINESVILLE PHYSICAL THERAPY NEW PATIENT REGISTRATION **PLEASE PRINT CLEARLY AND FILL IN ALL INFORMATION** HOW DID YOU HEAR ABOUT OUR CLINIC? Doctor (name) Family Member (name) Friend (name) GPT STAFF
California Cardiovascular and Thoracic Surgeons
California Cardiovascular and Thoracic Surgeons 168 North Brent Street, Suite 508 Ventura, CA 93003 Telephone (805) 643-2375 Fax (805) 643-3511 Your assistance in completing the following information thoroughly
Welcome to Our Practice
Welcome to Our Practice Greater Baltimore Medical Center (GBMC) welcomes you to our practice. We are dedicated to providing you with the kind of care that we would want for our own loved ones. This Information
Patient Registration Form
Patient Registration Form Patient Information Patient Name (Last, First, M.I.): Birth Date: / / Social Security Number: Sex (Circle One): Male / Female Race (Circle One): Asian/African American/American
My Doctor at WIM is: Dr. Azam Dr. Cohen Dr. Huynh Dr. Jacobellis Dr. McCarthy Dr. Taylor (CIRCLE ONE)
In order to serve you promptly, we need the following information. Fill out each item or put N/A (not applicable). Please Print Clearly. WESTFORD INTERNAL MEDICINE, P.C. My Doctor at WIM is: Dr. Azam Dr.
PATIENT DEMOGRAPHICS. Primary Insurance: Policy #: Group #: Secondary Insurance: Policy #: Group #:
TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:
Premier Obstetrics and Gynecology
, FL 33607, FL 33635 Patient General Information Name Birth date Age Social Security # Drivers License Home # Cell # Work # Street Address City State Zip Code Email Address Occupation Employer Spouse s
All 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
DeMercy Dental Crabapple Road, Ste. 140 Roswell, GA
PATIENT REGISTRATION (Please print) Patient s Legal Name: Last First Middle Preferred Name: Street Address: City St Zip Phone Numbers: Home Cell Work Email address: Which method is best to confirm appointments
WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely.
Page 1 of 4 WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely. Date: Dr: Chart #: Patient s Name: First MI Last Patient s
NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX
PATIENT INFORMATION NAME (LAST, FIRST, MIDDLE) SSN# BIRTH SEX ADDRESS CITY, STATE & ZIP CODE EMAIL: MAILING ADDRESS (IF DIFFERENT FROM ADDRESS) CITY, STATE & ZIP CODE HOME PHONE CELL PHONE OTHER PHONE
DILIP 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:
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 (
ELYSE 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.
Island ObGyn Joseph F. Lang, MD
Island ObGyn Joseph F. Lang, MD Patient Name: Billing Address: City: ST: Zip: Other Address: City: ST: Zip: of Birth: Social Security Number: Home Phone #: Work Phone #: Cell Phone #: Email Address: Pharmacy:
Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other
PATIENT REGISTRATION First Name: Last Name: Middle: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle Initial:
NARRA DERMATOLOGY AND AESTHETICS (425) Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields)
NARRA DERMATOLOGY AND AESTHETICS (425) 677-8867 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name Address Last First Middle Street & Apt
Sinha Clinic Foxfield Road, Suite 240, St. Charles, IL Office: (630) Fax: (630)
2560 Foxfield Road, Suite 240, St. Charles, IL 60174 Office: (630) 762-9606 Fax: (630) 762-9605 www.sinhaclinic.com info@sinhaclinic.com Patient Name: Date: Home Phone: ( )- Cell Phone: ( )- Preferred
PATIENT 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
Welcome to Compass Medical!
ELECTRONIC FORM DISCLAIMER: Compass Medical is deeply committed to protecting our patient's rights to privacy and safeguarding patient information. Please know we are working hard to bring our patients
Welcome To Our Office
Welcome To Our Office Date: Patient Name: SSN Date of Birth Address City State Zip Home Number:( ) Cell:( ) Work Number:( ) Email Address: Occupation (student) Employer (grade) Primary Care Physician Phone
Bergen County Gynecology, P.C.
PATIENT INFORMATION LAST NAME FIRST NAME MIDDLE MAIDEN NAME (IF ANY) DATE OF BIRTH SS# PLACE OF BIRTH MARITAL STATUS RACE ETHNICITY PREFERRED LANGUAGE OTHER LANGUAGES SPOKEN ADDRESS CITY ST ZIP HOME PHONE
HAMILTON 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:
Pediatric & 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,
PATIENT REGISTRATION FORM Patient Information. Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: Address: Street
Today s Date: Patient ID # [for office use only] Referring Physician PATIENT REGISTRATION FORM Patient Information Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: For Minors please
Center 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
Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male
Patient Information Patient Name: Last First Middle Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: of Birth: / / Social Security #: - - Marital Status:
PATIENT 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
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:
Last Name: First Name: MI: Date of Birth: / / Sex: Home#: Cell#: Address: City: Zip:
PATIENT REGISTRATION FORM DATE: PATIENT INFORMATION Last Name: First Name: MI: Date of Birth: / / Sex: Home#: Cell#: Address: City: Zip: Emergency Contact: Phone: Alt: Email: Primary Care PHYSICIAN Name:
Patient Name: First Middle Last Address: Number Street (Apt#) City State Zip Address: Okay to Statement? Yes No
****For Internal Use Only**** Name DX Office Ins Today's Date: How did you hear about us?: Patient Name: First Middle Last Address: Number Street (Apt#) City State Zip Email Address: Okay to Email Statement?
PEDIATRIC PATIENT INFORMATION
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
DATE: PRIMARY LANGUAGE SPOKEN: PATIENT S LOCAL ADDRESS: (Street) (City) (Zip) PERMANENT ADDRESS (IF DIFFERENT):
DATE: PRIMARY LANGUAGE SPOKEN: PATIENT NAME: _ Nick Name: (Last) (First) (Middle) CHECK ONE: SEX: M F CHECK ONE: MARRIED SINGLE WIDOWED DIVORCED RACE: _ DATE OF BIRTH: SOCIAL SECURITY: PATIENT S LOCAL
If you have questions about how much your fee will be, you may stop by or call with your income information before your appointment.
238 Arsenal Street, Watertown, NY Family Practice Office: (315) 782-6400 Fax: (315) 782-1330 Adult Office: (315) 782-9903 Fax: (315) 788-0087 Dental Office: (315) 788-9834 Fax: (315) 788-5456 7785 N. State
VEIN CENTER OF VENTURA
168 N. Brent St., #508 Ventura, CA 93003 Tele: (805) 643-2855 Fax: (805) 643-3511 PATIENT INFORMATION Name of Birth SS # Marital Status: Sex: Home Address City State Zip Email Mailing Address (if different)
Advanced Podiatry. W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted.
W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted. Date How did you hear about us? (Be Specific Please) First Name Last Name
DEMOGRAPHICS & BILLING INFORMATION
Jeffrey B. Russell, MD, FACOG, Director Board Certified Reproductive Endocrinology & Infertility 4745 Ogletown-Stanton Road Suite 111 Newark, DE 19713 Tel: 302-738-4600 Fax: 302-738-3508 556 South DuPont
WOMEN S PREMIER OBGYN REGISTRATION FORM
WOMEN S PREMIER OBGYN REGISTRATION FORM Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: q Miss q Ms. Marital status (circle one) Single / Married / Divorced / Sep / Widow Is
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)
Address: City: State: Zip: Home#: ( ) Mobile#: ( ) Work#: ( ) Date of Birth: / / Age: Sex: SS#: - -
Date of Appointment: Patient's Legal Name: Email Address: (Your email will enable your patient portal access to your medical records) Address: City: State: Zip: Home#: ( ) Mobile#: ( ) Work#: ( ) Date
Name: Social Security# Address: City: State: Zip: Date of Birth: Phone: Cell: *Employer: Phone:
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