Today s Date: / / Person filling out this form: Patient s Name: First Last Nickname

Similar documents
PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT

Chong S Kim, MD ENT and Facial Plastic Surgeon

PEDIATRIC REGISTRATION FORM

Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:

Worcester Kids Dentist 41 Lancaster Street, Worcester, MA Child Health History. Name of Child

Patient Information. Insurance Information

EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014

Name (Last, First, MI): Date of Birth: / /

ROBERT H. OLIVER, M.D., PLLC Otolaryngology Head And Neck Surgery Otolaryngic Allergy Chart #

RESPONSIBLE PARTY DEMOGRAPHIC INFORMATION

HIPAA PATIENT CONSENT FORM

Mountain West Pediatrics & Bedtime Kids Care. Patient Demographics

Patient Information Last Name First Name Middle Initial

Patient Registration Form This form is posted on our website

SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM

New Patient Registration Form

Little Peaches Pediatric Dentistry

PEDIATRIC UROLOGY ASSOCIATES P.C. PATIENT REGISTRATION FORM

PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:

Anthony Sparano, M.D.

WELCOME TO OUR PRACTICE! We look forward to seeing you very soon.

SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120

New Patient Packet Please print and complete the following 6 pages. Bring the completed forms to your scheduled appointment. Thank you!

New Patient Packet. Patient Name: Today s Date: Last First MI. Preferred Name: Gender: Birth Date: Apartment Number

HIPAA Authorization Release Form

CHILD S REGISTRATION & HISTORY

SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM

Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D

Arthur M. Cotliar, M.D. & Staff

Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN

Patient Health History Form

ENT FACULTY PRACTICE

PATIENT INFORMATION. Parent/Legal Guardian #1: Name: Date of Birth: / / Occupation/Employer: SS#: Work phone: Mobile: Home: address:

PATIENT INFORMATION PRIMARY INSURANCE INFORMATION

PAYMENT POLICY: Payment or partial payment is required on the day of visit.

KIDS PLACE ORTHOPEDICS 3742 KATELLA AVE., STE 303, LOS ALAMITOS, CA ORTHOPEDIC HEALTH HISTORY

PATIENT REGISTRATION SOCIAL SECURITY NUMBER:

INTERNATIONAL CRANIOFACIAL INSTITUTE

VASCULAR HEART & LUNG ASSOCIATES

EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE

Patient Registration Form

David L. Rothman, dds Pediatric Dentistry

Jandali Plastic Surgery

Name. Name. Name Employer Occupation Relationship to patient Work Phone Ext. # DOB Soc. Sec. # Home Phone Cell Phone Address

Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:

CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION

INFANT / PRESCHOOLER For Patients Infant through Pre-K

Please Present Insurance Card at Each Office Visit

appointment checklist

Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA Phone: Fax:

BRAMLETT ORTHOPEDICS

Welcome to Pediatric Dentistry of Greenville!

Date of Birth: Age: Social Security #: Address: City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div

Healthy Smiles Start Here!

JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM

Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -

1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.

***PLEASE PRINT USING BLACK INK ONLY***

PATIENT INFORMATION NOTICE OF PRIVACY POLICY PATIENT ACKNOWLEDGEMENT

Buckland Ear, Nose & Throat, LLC. Medical History

ADVANCED VEIN & VASCULAR SOLUTIONS Board Certified Vascular Surgeons

West Houston Infectious Disease Associates. Address: Number Street Apt. No. City State Zip. Home Phone: Cell: Work:

Bellingham Arthritis & Rheumatology Center. 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F)

Patient Registration Form

PATIENT REGISTRATION FORM

HIPAA Authorization Release Form

MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information

NEW PATIENT INFORMATION Salutation First Name MI Last Name Nickname

Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.

INSURANCE INFORMATION

Green Hills Plastic Surgery Stephen M. Davis, MD, FACS

Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS

Rev. Your Address Street or P.O. Box City State Zip. Your Date of Birth / / SS# Phone numbers cell ( ) - home ( ) - work ( ) -

OFFICE VISIT CHECKLIST

Green Hills Plastic Surgery Stephen M. Davis, MD, FACS

Dr. Liat Corcia, Pediatric Endocrinologist Miami Pediatric Endocrinology, LLC

ERIC ROCKMORE, DPM, FACFAS

Georgia Foot & Ankle

CHILD S INFORMATION PARENTS INFORMATION

NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. Insurance Co. Name Name

CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.

Doc Bresler s Cavity Busters - New Patient History Form

PRIMARY INSURANCE TO FILE SECONDARY INSURANCE TO FILE

PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA

Beyond Limits Audiology School Age Case History

ADULT INFORMATION SHEET

creating beautiful smiles

Caritas Medical Center, LLC

Child s Name: (First) (Middle) (Last)

GIVE US STRENGTH PHYSICAL THERAPY

LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# ADDRESS:

MICHAEL E VILLANO, MD, FACS Board Certified, American Board of Otolaryngology, Head and Neck Surgery PATIENT INFORMATION

New Patient Packet. Thank you for choosing Shasta Regional Medical Group. Our office looks forward to serving you.

MarinEyes 901 E Street San Rafael CA 9490 Tel: CITY STATE ZIP CODE HOME PHONE CITY STATE ZIP CODE

If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:

PATIENT REGISTRATION FORM Account #:

Part Four: Who is Accompanying the Child Today? Part One: Tell Us About Your Child. Part Five: Referral. Part Six: Person Responsible for Account

PATIENT INFORMATION FORM PLEASE COMPLETE THE FOLLOWING INFORMATION

Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided.

Marietta Podiatry Group Patient Registration Form

Transcription:

Connecticut Pediatric Otolaryngology David E. Karas, MD Eric D. Baum, MD Susannah Hills, MD Wendy Mackey, APRN Lisa Gagnon, APRN Melissa Dziedzic, APRN New Patient Information Form (available at www.ctentkids.com) Bring your child s insurance card and referral form (if required) to every visit. Co-payments must be paid in full at the time of the appointment. Please bring any important tests and x-rays as well. Today s Date: / / Person filling out this form: Patient s Name: First Last Nickname Date of birth: / / Gender: Male Female Address: Street City State Zip Phone (circle the best number to reach you during the day): Home: ( ) Cell: ( ) Work: ( ) Other (specify): ( ) Email (we will not share your address with anyone): Please check if we may contact you by email for appointment reminders clinical follow-up Name of your pharmacy: Street & town: School or daycare: Grade: Special interests, hobbies, extracurriculuar activies: Parent Information (please check): Mother Father Stepmother Stepfather Name: Lives with patient? Yes No Employer: Occupation: Parent Information (please check): Mother Father Stepmother Stepfather Name: Lives with patient? Yes No Employer: Occupation: Names and ages of other children in the family: Pediatrician or Primary Care Provider: Name Address Phone Others (doctors, therapists, etc.) involved in your child s care: Who referred you to us? Primary Care Doctor Self Other

Medical History Patient s Name: What is the problem you are here for today? When did this problem begin? Has there been any treatment for this problem yet? Medications (and doses if known) your child is taking: Medication and food allergies and the reaction that occurs: Overnight hospitalizations and why: Prior surgeries: Patient s weight: lbs. (OR) kg. Are your child s immunizations up to date? Yes No Has your child ever been diagnosed or treated for problems in any of the following body systems? Please explain. EYES EAR, NOSE & THROAT Vision problems / Crossed eyes Frequent ear infections / Hearing loss / Ringing / Sinus Infections Mouth breathing / Snoring / Difficulty swallowing/ Frequent strep throat or tonsillitis / Voice problems, Speech problem / Language delay HEART RESPIRATORY & LUNGS GASTRO- INTESTINAL (GI) Abnormal murmurs / Heart defect Wheezing / Asthma / Recurrent croup / Pneumonia / Excessive coughing RSV Bronchiolitis / Bronchitis Feeding difficulties, Gastroesophageal Reflux / Liver disease / Hepatitis / Colitis / Vomiting / Diarrhea / Frequent stomachaches ENDOCRINE Diabetes / Thyroid / Excessive thirst or hunger / slow or excessive growth Init:

URINARY & KIDNEY MUSCULO- SKELETAL / JOINTS & BONES NEUROLOGICAL & BRAIN PSYCHOLOGICAL & BEHAVIORAL SKIN HEMATOLOGIC ALLERGY & IMMUNOLGY CONGENITAL ANOMALIES & GENETIC PROBLEMS Urinary infections / Kidney problems / Bedwetting Arthritis / Fractures (including nasal fracture) / muscle weakness / Limp Headaches / Migraines / Seizures/convulsions / Motor Tics / Autism / Pervasive developmental delay (PDD), Meningitis, Fainting or dizziness, Cerebral Palsy (CP), head injury or trauma, Depression / ADD / Hyperactivity / Drug problem / Psychiatric disorder Eczema / Recurrent rashes / Hives Anemia / Bleeding tendency / Blood disorder / Lymphoma / Leukemia, Sickle Cell Disease Immune deficiency / HIV / AIDS Environmental allergies: Syndrome / Abnormal facial development / Cleft lip or palate / Craniofacial abnormality Family Medical History Has any member of the patient s extended family experienced problems with any of the following? If so, please specify who (relation to the patient) and explain the problem: Bleeding Problems: Anesthesia Problems: Ear/Nose/Throat Issues: Genetic/Chromosome Issues: Hearing Issues: Init:

Financial Agreement It is the patient or the patient s/guardian s responsibility to pay for the services rendered. If the patient/guardian provides us with current health insurance information, we will process the claim directly with the insurance company. The patient/guardian is responsible for any co-payment, deductibles, or other amounts not payed by your insurance company. We accept cash, personal checks, Visa and Mastercard. When necessary, we will do our best to work out financial arrangements satisfactory to both the patient and this medical practice. Once an arrangement is made, the patient/guarantor is expected to follow that payment plan. Questions about your insurance coverage and benefits should be directed to the insurance company. By signing at the bottom of this page, you authorize all payments due for medical benefits to be made directly to Connecticut Pediatric Otolaryngology, LLC (CPO). Privacy Statement A notice of Privacy Practices is available to all patients and is posted in the office. Our privacy policy and information management are in compliance with applicable laws, including The Health Insurance Portability and Accountability Act of 1996 (HIPAA). By signing at the bottom of this page, you authorize Connecticut Pediatric Otolaryngology, LLC to release any information pertaining to the examination, treatment, history and medical expenses to my insurance carrier(s) for claim processing purposes. This release may include review, copying and/or electronic transfer of documents for consideration/payment of claims by the insurer. Authorization for Access/Release of Information I authorize Connecticut Pediatric Otolaryngology, LLC and released entities to obtain information from those that have been directly involved in my child s care as it pertains to his/her continued care at Connecticut Pediatric Otolaryngology, LLC. INFORMATION TO BE RELEASED OBTAINED (VERBAL OR WRITTEN FORM) AS FOLLOWS: Dates of service: all available medical records OR (specify dates): Purpose of disclosure: coordination of medical care OR (specify): I understand that this authorization will expire one year after I have signed the form or other time frame as specified: I understand that I may revoke this authorization at any time by notifying a request in writing, and it will be effective on the date notified except to the extent action has already been taken in reliance upon it. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy regulations. I understand that I am not required to sign this form in order to receive treatment or payment for my care. I understand that there may be a fee for a copy of my medical record. I hereby certify that I have read the financial agreement, privacy statement and authorization for access/release of information. I agree to accept full financial responsibility for payment of the charges incurred by the named patient, including costs of collection and a reasonable attorney s fee incurred in the collection of any amounts not paid, as requited. I also agree to the specifications of the privacy release and authorization for information release. Signature of parent/legal guardian/authorized person: Date:

Name of insured: Relationship to patient: Insurance Information Bring your child s insurance card and referral form (if required) to every visit. Co-payments must be paid in full at the time of the appointment. You do not need to fill out this page if you have the child s insurance card (we can just copy the card) Primary Insurance Carrier: ID#: Group #: Address to submit the claim: Street City State Zip Code Policy Holder s Name: SS#: Date of Birth: / / Relationship to Child: Employer Name: Secondary Insurance Carrier: ID#: Group #: Address to submit the claim: Street City State Zip Code Policy Holder s Name: SS#: Date of Birth: / / Relationship to Child: Employer Name:

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback