73 W. Church Street, Stevens, PA Telephone (717) Fax (717)
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1 Doreen Bett, D.O. Susan K. Ciampaglia, D.O., FACOI James A. Groff, D.O., FACOI Navdeep Kaur, M.D. Jeffrey N. Levine, D.O., FACOI Jeffrey L. Martin, M.D., FASN Charles H. Rodenberger, M.D. David I. Somerman, D.O. Rajiv Sharma, M.D. Marc H. Weiner, M.D. Kathryn E. Couch, CRNP Cheryl L. Good, CRNP Jennifer L. Groff CRNP Dana R. Nikles, CRNP Anne M. Pryzbylkowski, CRNP Allison M. Sileo, CRNP Dear Patient: Welcome to Hypertension and Kidney Specialists. The physicians and staff of our medical practice are dedicated to providing you with the highest standard of medical care. Enclosed you will find two forms: Patient History Form & Patient Information Form. Please fill out these forms, and present them to the receptionist, along with your insurance card, prescription card and list of medications, when you arrive for your appointment. If you filled out the forms online through mylghealth, please print them and bring them with you to your appointment. We encourage you to bring all your medications with you or bring a detailed medication list. This review of medications should include any over the counter drugs you may be taking. Please note that if your insurance requires a referral it is your responsibility to have this at the time of service. Unfortunately your appointment will have to be postponed until you obtain a referral. Insurance co-pays are due at the time of service. Failure to provide your co-pay will result in the cancellation of your appointment. Please arrive fifteen (15) minutes prior to your appointment, to ensure that all of the necessary paperwork has been completed. Please be prepared to provide a urine sample, in the office, at this time. If you have any questions or concerns prior to your appointment, please feel free to call our office and our staff will be happy to assist you. Thank you, HKS Physicians Appointment Location Lancaster General Health Campus Cocalico Center for Health Bldg Harrisburg Pike 73 West Church Street Suite 310 Stevens, PA Lancaster, PA Harrisburg Pike, Suite 310, Lancaster, PA Telephone (717) Fax (717) W. Church Street, Stevens, PA Telephone (717) Fax (717)
2 Patient History Form The following information is very important to your health. Please take the time to fully and accurately fill out this form. Name: Date of Birth: Which physician or practice referred you to Hypertension and Kidney Specialists What is your understanding of why you are being seen? Current Medical Problems (examples: diabetes, high blood pressure, high cholesterol, other medical problems for which you take medications, etc) 1) 4) 2) 3) 5) 6) Others Past Medical Problems that are no longer active (example heart attack, stroke, cancer that is in remission) 1) 2) 3) 4) 5) 6) Others Past Surgeries you have had (example appendix removed, gallbladder removed, etc) 1) 2) 3) Others Do you have a History in Your Family of: Have you or do you: Kidney Disease including anyone Smoke No Yes Quit? on dialysis or needed kidney transplant No Yes Drink Alcohol No Yes Hypertension high blood pressure No Yes if yes how much Blood or protein in the urine No Yes Ever used illicit or Rheumatologic condition such as No Yes recreational drugs No Yes Lupus, Rheumatoid Arthritis No Yes if yes which ones If yes to the above, please explain who Drink caffeine No Yes if yes how much
3 Are you allergic to any medications or environmental allergens (food, bees, etc): Have you ever received a Pneumonax (pneumonia vaccine)? No Yes (if yes when) Did you receive influenza vaccine this year? No Yes List All Medications (including Over the Counter and herbal medications) currently being taken or stopped in last month. Please bring all your medication bottles with you to your appointment. Do you follow special diet (low salt, diabetic, etc) Do You Have or Have History of Weight Loss or Weight Gain No Yes Pain with urination No Yes If Yes how many pounds Blood in urine No Yes Fevers or Night Sweats No Yes Kidney stones No Yes Vision Problems No Yes Frequent Bladder Infection No Yes Bleeding in eye from high blood Are you up at night to urinate No Yes pressure or diabetes No Yes Painful Joints No Yes Diabetes in your eye(s) No Yes Numbness in hands or feet No Yes Problems with Sinuses No Yes Weakness in arms or legs No Yes Persistent Cough No Yes Bruise or bleed easily No Yes Coughing up blood No Yes Skin Rash No Yes Tuberculosis or exposure to Tb No Yes Depressed Mood No Yes Chest pain or tightness No Yes Confusion No Yes Swollen legs, feet, around eyes No Yes Excessive Thirst No Yes Irregular or rapid heart beat No Yes Loss of appetite No Yes Do you take medications for upset Bad taste in your mouth No Yes stomach/heartburn No Yes Have you ever been denied Nausea/vomiting No Yes ability to donate blood No Yes Jaundice or Hepatitis No Yes I attest that the above information is true and correct to the best of my knowledge. Name: Date: Office use only: Reviewed by Date:
4 Patient Information Form Account No Name: (First) (M.I) (Last) Address: City: Date of Birth: / / SSN#: - - State: Zip: Sex: ( ) Male ( ) Female Marital Status: ( ) S ( ) M ( ) D ( ) W Language Preference if not English: Race: (Black/African American, White, Asian, Pacific Islander, Declined) Ethnicity: Do you consider yourself Hispanic or Latino: ( ) Yes ( ) No ( ) Declined Emergency Contact: Spouse: (or someone who lives in your home) Phone #: Other(s): Phone #: (children/siblings *someone who does not live in your home) May we discuss your medical condition with your emergency contact(s)? ( ) Yes ( ) No Communication Methods: * check all that apply ( ) Preferred Daytime Phone #: ( ) Evening Phone #: ( ) Cell Phone #: ( ) Other: ( ) May leave message to return call ( ) Ok to leave detailed message ( ) Not ok to leave message ( ) Patient Portal **coming soon ( ) **coming soon Cont d on page 2 Exec:HIPAA/Patient Info 2013 Page 1 of 2
5 Patient Information Form Account No Release of Information: ( ) I authorize the staff of HKS to release information and/or discuss my care with the following person(s). ( ) Spouse/Significant other: ( ) Child(ren): ( ) Sibling(s): ( ) Other: This Release of Information will remain in effect until terminated by me in writing. **By signing this I understand that only the persons listed above are authorized to discuss my medical care. Anyone requesting to discuss my medical care that is NOT listed above will be refused. ** If you have a designated POA (Power of Attorney), please provide documentation. Who is your Family Doctor: Please list any other Specialists that you see: 1. (name) (group) 2. (name) (group) 3. (name) (group) 4. (name) (group) Signature: Date: Exec:HIPAA/Patient Info 2013 Page 2 of 2
WELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
WELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
Please complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
General Internal Medicine Clinic - New Patient Questionnaire
Internal Medicine Associates of Southern New Jersey Robert Schwartz. D.O. University Executive Campus Marc H. Mlchelson. D.O., FAC.O.I. 151 Fries Mill Road,.Suite 400 James C.D'Amico, D.O. Turnersville,
Name(last, first): Home Phone: Cell Phone: address: Date of birth: SSN:
36320 Inland Valley Drive Suite 201 Wildomar, CA 92595 Name(last, first): Home Phone: Cell Phone: Emergency contact/ Phone: Relationship to Emergency Contact: E-mail address: Date of birth: SSN: Would
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
Adult Demographics Form
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
FOLSOM CARDIOLOGY. Registration Form. Office Use Only: Patient Acct #
FOLSOM CARDIOLOGY Please complete forms in black ink only Registration Form Office Use Only: Patient Acct # Name: Date of Birth: Address: Street City State Zip Code Phone: Work: Cell: Marital Status: S
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:
TIMOTHY B. COLE, MD ALLISON TRAVIS, MD 7300 Eldorado Parkway, Ste 260, McKinney, TX 75070 Phone: 972-747-0440 / Fax: 972-747-0441 PATIENT REGISTRATION FORM Date: Last Name: First Name: Initial: Address:
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
Thank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important
Vanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology
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NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Ethnicity: Hispanic Non-Hispanic Mr. Mrs. Ms. Miss Is this your legal name? If not, what is your legal
Medical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (PLEASE FILL OUT COMPLETELY) ****************************************************************************** LAST NAME: FIRST NAME: MI: ADDRESS: CITY: STATE: ZIP: PHONE # S: HOME:
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced
PATIENT INTAKE AND HISTORY FORM
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Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
New Patient Information Form
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Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
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New Patient Information. Which Physician will you be seeing today? How did you hear about our practice?
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PERSONAL INJURY QUESTIONNAIRE
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I choose not to specify
Today s Date: / / Welcome to Arena Chiropractic! Your Health History is important to us. Please follow the instructions throughout the form and provide us with as much information about yourself as possible.
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
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PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
GASTROCARE, P.C. Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken):
GASTROCARE, P.C. DR. A.B. REDDY, M.D., F.A.C.G. DR. REKHA KHURANA, M.D. Referring Physician: First Name: Date of Birth: Last name: Age: Pharmacy (include location): Fax Number: Email Address: Gender: Male
Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
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IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.
Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Home Phone #: Work Phone #: Cell
Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL. Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed
Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed Address Alternate Address STREET CITY STATE ZIP STREET CITY
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Circle Preferred Phone Number Home
medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
PATIENT NAME: DOB: SS#: NAME OF PARENTS (if patient is a minor) PATIENT REGISTRATION HOME ADDRESS HOME PHONE: CITY: STATE: ZIP: CELL PHONE: MAILING ADDRESS (if different) CITY: STATE: ZIP: EMPLOYER: EMPLOYER
**************************************************************************
Patient Information Form Date: Name: First MI Last Address: Street Apt City State Zip Code Date of Birth: Social Security Number: - - Home Phone: Work Phone: Cell Phone: Email: Primary Language: (Fill
Past Skin History (Please check the applicable boxes to the patient s history or choose the first box)
Patient: First M.I. Last Date of Birth: Address: City: State: Zip Code: Responsible Billing Party: Social Security #: DOB: Home Work: Mobile: Best Contact number for confirmation calls is: Email (Required):
Patient Registration Form
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ALLERGIES (food,latex,other)
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GoPrivateMD General Information & History
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Patient Interview Form
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Renal Remission and Hypertension Consultants PLLC
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PATIENTS DEMOGRAPHICS
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The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
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Patient Information. Legal Name: First Middle Last. Street City State Zip
Patient Information Legal Name: Home Address: First Middle Last Street City State Zip Gender: (circle one) Male Female Date of Birth: Social Security #: - - mm / dd / yyyy Email: Marital Status: Primary
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE Today s : Patient Name: DOB: Race White/Caucasian Black/African American Asian Native American Alaskan Native Native Hawaiian Pacific Islander Other: Preferred Language:
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Schodack Internal Medicine and Pediatrics. Annual Physical-Female
Schodack Internal Medicine and Pediatrics Annual Physical-Female Please Fill out this form (or have your caregiver complete it) and discuss with your medical provider. Thank you! Please Mark the preferred
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
HEART CENTER OF NORTH TEXAS, P.A. CARDIOLOGY
HEART CENTER OF NORTH TEXAS, P.A. CARDIOLOGY Dear Welcome to the Heart Center of North Texas. Your appointment has been scheduled for at with Dr. Mott. Your appointment will be at our Weatherford office
Race (Check one): White Black Asian American Indian/Eskimo/ALEU Hawaiian Native/Pacific Islander Other
Please mail or fax to: Dallas Transplant Institute Pre-Transplant Group 1420 Viceroy Drive Dallas, TX 75235 Fax: (214) 366-6088 Donor Name: SS#: Date of birth: Age: Sex: Male Female Address: City/State/Zip
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
ARTHRITIS AND ORTHOPEDIC MEDICAL CLINIC
Name: DOB/Age: Height: Weight: Today s Date: PRESENT ILLNESS: What medical problem brings you to the office? Is this problem related to an injury? When? Work Related? What treatments have you received?
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY Tel # PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY 10016 Tel # 212-481-0064 PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A Last Name First Name Age Date Of Birth Sex Marital Status
Dear Sir or Madam, APPOINTMENTS
Dear Sir or Madam, Welcome to Pain Specialists of Southern Oregon. We are committed to providing you with state-of-the-art interventional pain management and clinical services. Thank you for choosing us