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Patient Information: Name:!!!! Last!!!! First!! Initial! Sex: Date of Birth: Age: SSN: Phone Numbers:!!!!!! Home!!! Work!!!! Cell Patient Address:! Street Address!!! City!!! State Zip Code Race: Black/African American Caucasian Hispanic Asian American Indian Other Martial Status: Married Single Divorced Widowed Student Emergency Contact: Phone No: Relationship to patient: Email address: Reason for Visit: How long problem existed? Employer:! Occupation: Referring Physician: Address:!!! Phone No:! Pharmacy: Name, address & no:!!!! Insurance Information: Do you have Medical Insurance: Yes! No If yes, in order to file your insurance, you must present a state issued photo ID. Primary Coverage: What is your insurance coverage: Policy no: Policy holderʼs name: Policy holderʼs date of birth: Policy holderʼs SS#: / / Patient Relationship to policy holder:

Insurance (continue) Secondary Insurance: What is your insurance coverage: Policy no: Policy holderʼs name: Policy holdʼs date of birth: Policy holderʼs SS#: / / Patient relationship to policy holder: Financial Agreement: The undersigned hereby authorize the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I agree and acknowledge that my signature authorizies the physician to submit claims for benefits for services rendered or services rendered without my signature on each and every claim to be submitted for myself and/or dependent(s) and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I hereby authorize! Insured Name!!!!!!Insurance Company Name pay and here by assign directly to all benefits, if any, otherwise payable to me for services described to the attached forms. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and paid to will be credited to my account in accordance with the above assignment. Please be aware that you may be seen by a Physician Assistant.!!!!!!!! Initial We require a 24 notice for cancellations/rescheduling of appointments or there will be a $25 fee applied to your account. There is also a $35 charge for any returned checks,!!!!!!!!! Initial Responsible Party: Name of Guarantor!! Consent to Treatment I give consent for myself or my child/dependent to receive medical treatment from.! Responsible Party Signature!!!! Date

Privacy Practices Notice: I was given and reviewed a copy of the Privacy Practice Notice for :! Signature!!!!!!!! Date Medical Information: Allergies: Medications: Personal Medical History Which of the following conditions are you being treated or have been treated for for in the past. (Check the appropriate box)!!!! Anemia or Blood problems!! Arthritis!!! Asthma!!!! Blood pressure / High / Low!! Cancer!!!! Depression / Anxiety!! Diabetes!!!! Ear problems!!! Eye disorder / Glaucoma!! Headaches / Migraines!! Heart disease / Murmur / Angina! Heartburn!!!!!! High Cholesterol!!! Kidney / Bladder problems!! Liver problems / Hepatitis!! Lung problems / cough!! Neurological problems!! Psychiatric care!!! Seasonal allergies!!! Shortness of breath!! Sinus problems!!! Stroke!! Swollen ankles!!! Tonsillitis!! Thyroid problems!!! Ulcers / colitis!! HIV / AIDS!!!!!!!!!!!! Past Surgical History! (Check the appropriate box)!!!!!!!! Abdominal Surgery!!! Appendectomy!! Back Surgery!!!! Biopsy!!!! Bladder Suspension!!! Brain Surgery!!! Breast Surgery!!! Cervix Surgery!!! Colonoscopy!!!! C-Section

Past Surgical History (continued)!(check the appropriate box)!! Cyst!!!!! Eye Surgery!! Ganglion Cyst!!! Hermorrhoidectomy!! Hernia Repair!!! Hip Replacement!! Hysterectomy!!! Knee Surgery!! Kidney Stones!!! Laparoscopy!!! Liposuction!!!! Lumpectomy!! Tonsillectomy!!!! Tubal Ligation!! Vasectomy Family History! (Check appropriate box and list family member)!!!!!!!! List Family Member Cancer / Tumor!!!!!! Colon Polyps!!!!!! Crohnʼs Dieas!!!!!! Diabetes, Insulin dependent!!!! Diabetes, Non-insulin dependent!!! Diabetic Retinopathy!!!!!! Graves Disease!!!!!! Hay Fever!!!!!! Heart Disease!!!!!! Heart Problems!!!!!! HSV!!!!!!!! Hypertension!!!!!!! Kidney Disease!!!!!! Leukemia!!!!! Lupus!!!!!!! Ovarian Cancer!!! Peptic Ulcer!!!!!!! Sickle Cell Disease!!! Stomach Ulcer!!!!!! Stroke!!!!!!!

Family History (continued)!! (Check appropriate box and list family member) Thyroid Disease!!! Tuberculosis!!! Uterine Fibroids!!!!!! Vaginal Cancer!!!!! Vitiligo!!!! Warts!!!!!!! Social History Do you currently smoke or chew tobacco? Yes No If yes, how many packs per day? Do you drink alcohol, beer or wine? Yes No How many drinks per week? Do you drink coffee and /or tea? Yes No How many cups per day?

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