WELCOME- OUR PHILOSOPHY

Similar documents
Dear Valued Patient, Your Insurance Card A Picture ID Any disks with MRI, CT Scans, or Xray images

Policies and information:

Patient Welcome Form!

Xcel Rehab. Patient Information

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:

Patient Information Form

Thank you for choosing Dr. Jesse DeLee for your care. The staff and Dr. DeLee would like to ensure your experience is a pleasant one.


Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other

4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /

REASON FOR TODAYS VISIT Is this injury / condition related to your..

Weitz Sports Chiropractic and Nutrition. Ben Weitz D.C. C.C.S.P th Street, Suite 201. Santa Monica, CA Name: Referred By:

DATE: PRIMARY LANGUAGE SPOKEN: PATIENT S LOCAL ADDRESS: (Street) (City) (Zip) PERMANENT ADDRESS (IF DIFFERENT):

PATIENT INFORMATION Patient Name: Last First Middle Initial. Address. Street or P.O. Box City, State Zip

First Name: M.I. Last Name: Date of Birth: Marital Status (circle one): Never Married Married Divorced Legally Separated. Widowed Partner Other

LAS VEGAS ENDOCRINOLOGY

CENTRAL FLORIDA NEUROSURGERY INSTITUTE Hunaldo J. Villalobos, M.D., FAANS, FACS

AUTHORIZATION FOR TREATMENT

PATIENT REGISTRATION INFORMATION FOR MINORS

South Lake Pain Institute

DILIP TAPADIYA, M.D. INC. Demographic Form

New Patient Registration Packet

Physical Therapy with care and knowledge

If you should have questions prior to your visit, please feel free to call our office at We look forward to seeing you.

Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION

Physical Therapy Services of Ottawa County Patient Registration Form

COREY M. NOTIS, M.D., P.A.

CALIFORNIA ORTHOPAEDIC INSTITUTE MEDICAL ASSOCIATES, Inc.

DeMercy Dental Crabapple Road, Ste. 140 Roswell, GA

Center of Excellence in Spinal Care. Patient Information. If Patient is a minor Guarantor Name: If Patient is a minor Guarantor Social Security #:

4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /

Patient Demographic Sheet Please use Black ink only & print clearly Referred by:

Dr. Jeff Eidsvig, D.C., TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas Patient Insurance Information

Name: last First middle Address: street city state zip code Mailing Address: ( if different) street city state zip code

Welcome to Southwest Diagnostic Center!

PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber

Advantage Physical Therapy Patient Registration

Patient Registration. D. INSURANCE (if applicable)

Please list all current medications and supplements that you are taking:

WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU

WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely.

Please verify that Baker Allergy, Asthma, and Dermatology is in network with your insurance plan before your appointment date.

221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION. Mailing Address: City: State: Zip: Birth Date:

5149 N. 9th Ave Suite G32 Pensacola, FL phone fax

NEUROLOGICAL INSTITUTE OF MICHIGAN PATIENT INFORMATION FORM

Corona-Temecula Orthopaedic Associates P H Y S I C A L T H E R A P Y A N D W E L L N E S S C E N T E R

Morris Medical Center, P.A.

Please print and complete all the enclosed forms and bring them to your first appointment.

Patient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM

Dr. Jeff Eidsvig, DC,ART,TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093

Demographics/Authorization Page (Front and Back) Patient Medical History Testing History Privacy Consent Form/ Financial Agreement (Front and Back)

New Braunfels Family Wellness Center 1135 West Mill Street New Braunfels TX, Office: (830) Fax: (830) NewBraunfelsWellness.

Please print and complete all the enclosed forms and bring them to your first appointment.

Today s date: PATIENT INFORMATION. Address:

Sierra Endocrine Associates Endocrinology, Diabetology & Metabolism

All Care Physical Therapy Center Directions: Please fill in all spaces, if not applicable, please put N/A.

Trinity Family Physicians

Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX (972)

Sinha Clinic Foxfield Road, Suite 240, St. Charles, IL Office: (630) Fax: (630)

Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications

PATIENT REGISTRATION FORM Account #:

INSURANCE INFORMATION

List any past surgeries that you have had throughout your lifetime (if none, circle NONE):

FOOT & ANKLE ASSOCIATES OF WYCKOFF. Dr. Edward R. Nieuwenhuis Jr./Dr. Edward R. Nieuwenhuis Sr./Dr. Edward F. Younghans

Patient Information. Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name:

Hunterdon Digestive Health Specialists New Patient Forms

New Patient Registration

Patient Registration. D. INSURANCE (if applicable)

Lake County Neuromonitoring, LLC Libertyville, Illinois Lake County Imaging, LLC P: Lakeshore Physical Therapy, LLC F:

APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation

Dear. If you have any questions, feel free to call our office. We look forward to seeing you. Sincerely,

PATIENT INFORMATION. Last Name: First Name: Middle Initial: Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: Weight: Mailing Address:

Patient name: LAST FIRST MIDDLE. Address: Responsible Party SS#: Required If patient a minor and/or full-time student. Employer: Occupation:

PRO SPORTS THERAPY, INC. (P.S.T.)

Welcome to Our Practice

Eugene Eye Clinic, LLC

New Patient Information

Patient Registration Form

PATIENT INFORMATION EMERGENCY CONTACT

Last Name First Name M.I. Street Address City State Zip. Home Phone ( ) Cell Phone ( ) Work Phone ( ) Emergency Contact: Name/Relation Phone Number(

LENNOX SPECIALTY GROUP

GAINESVILLE PHYSICAL THERAPY NEW PATIENT REGISTRATION HOW DID YOU HEAR ABOUT OUR CLINIC? PATIENT INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION CONTACT INFORMATION

PATIENT INFORMATION SHEET

PATIENT REGISTRATION FORM

Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male

CHAMBERS MEDICAL GROUP 1802 East Busch Blvd. * Tampa, FL * (813) * (813) fax

Automobile (No Fault) Insurance Assignment of Benefits

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

Upgrade My Credit Client Agreement

First Middle Initial Last. SSN: Date of Birth . Address: City: State: Zip: Home Phone: Cell Phone: Sex: M F

Dental Insurance: Primary Carrier: Employee #: Insured s SSN #: Insured Birth date: Group #: Phone #: Insurance Company Address: City: State: Zip:

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

NOTICE TO OUR PATIENTS

for / / at in (Provider name) (date) (time) (location)

FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C. PHYSICAL THERAPY INSTITUTE PATIENT INFORMATION SHEET

If patient is under 18 y/o, name of Parent/Guardian: Relationship to Patient: Address: (street) (city/state) (zip code)

SUBURBAN GASTROENTEROLOGY

PATIENT REGISTRATION

EMERGENCY CONTACT INFORMATION PATIENT EMPLOYER INFORMATION GUARANTOR / POLICY HOLDER INFORMATION INSURANCE INFORMATION

Transcription:

WELCOME- OUR PHILOSOPHY Dear Patient, Thank you for choosing me to provide your orthopedic care. My team and I will make every effort to treat you with courtesy, respect and kindness, while providing the highest level of care possible. I truly understand the frustration of having to complete new forms each time you see another physician; however, in order to help me treat you accurately and efficiently, I would appreciate it if you would take a few minutes to complete the attached forms as accurately and completely as possible. Please be sure to fill out a separate history sheet for each area of the body for which you have been scheduled for your appointment. I have found that two of the factors that create the greatest delay during office hours are the necessity for me or my physician assistant to personally complete these forms with or for the patient, and the insistence by patients that they be seen for a problem for which they are not scheduled as long as they are here. As a result the waiting time for other patients is increased as is the level of frustration for all of us. Your cooperation will enhance your experience with my practice. My staff and I spend a great deal of the time during the first visit educating our patients about their diagnosis and together determining a customized treatment plan that will best suit their needs. We feel that when our patients understand their own bodies and the numerous treatment options, they have more control of their problem and can be proactive in their treatment. I have found that if patients write down their questions it helps insure that they don t forget to ask for information that is important to them. As a result of this philosophy, and the occasional need to fit in patients with emergency conditions, we will at times find it hard to stay on schedule. Please know that we do respect your time, and we will make every effort to see you as close to your scheduled time as possible. We understand that schedules change and that there may be a need to cancel or reschedule your appointment. Please give us at least 24 hours notice so that we can offer your appointment time to another patient. I look forward to getting to know you and helping you with your orthopedic problem. Sincerely, Ben Rubin, M.D.

YOUR FIRST VISIT 1. Please read the patient welcome letter on our website which explains our philosophy of care. 2. Please complete the forms on our website: OSI Patient Registration Form Orthopedic Questionnaire General Health History 3. Insurance information Please bring your insurance card and a photo ID 4. Imaging studies Please bring any recent x-rays, MRI or CT scans related to your injury. Please bring a CD of the studies or the actual films, not just the reports 5. Clothing Female shoulder patients - please bring or wear a tank top, halter or sports bra Hip, knee and ankle patients please bring or wear a pair of shorts Neck and back patients will be provided with examination gowns

verified by: Insurance Information verified by: Patient Information Patient Registration First Name Middle Initial Last Name Date of Birth Social Security Number Gender Male Female Street Address City State Zip Code Marital Status (circle one) Primary Care Physician Married Single Divorced Widowed Phone number : Home Cell Work Email address Driver s License # Employer Emergency Contact Name Relationship Phone Date of injury/onset of symptoms Primary Insurance Carrier Was this an injury? NO YES If yes, Where did your injury occur? WORK AUTO HOME SCHOOL OTHER: Secondary Insurance Carrier Insured s Name: Insured s Date of Birth: Insured s Social Security number Insured s Name: Insured s Date of Birth: Insured s Social Security number ID # ID # Group # Group # Claims Address: Claims Address: Phone: Phone: Guarantor Responsible Party Patient Other (if other please fill in information below) Name: Date of Birth Relationship to patient: Street Address City State Zip Code Phone number Social Security Number Employer I hereby assign the insurance benefits to which I am entitled, directly to ORTHOPAEDIC SPECIALTY INSTITUTE, a medical group. I understand that I am financially responsible for all charges regardless of insurance verification, benefits and eligibility. I authorize release of medical records and information regarding medical history that is requested by the insurance company. A photocopy of this authorization is accepted with the same authority as original. Photo identification and insurance cards must be presented at the time of service to enable OSI to submit claims to your insurance carrier. Should identification and insurance cards not be presented, you will become a cash patient with payment in full due at the time of service. This agreement will remain valid from this day forward to include all future services relating to the above patient. SIGNATURE OF PATIENT/GUARDIAN DATE

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