Dr. Osvaldo Anez 462 Herndon Pkwy. Ste. # 101 Herndon, VA Fax:
|
|
- Lisa Poole
- 6 years ago
- Views:
Transcription
1 Dr. Osvaldo Anez 462 Herndon Pkwy. Ste. # 101 Herndon, VA Fax: Reason for visit: DO YOU HAVE A LIVING WILL? YES NO FIRST NAME M.I. LAST NAME MAIDEN NAME SOCIAL SECURITY # DATE OF BIRTH HOME ADDRESS APT # CITY STATE ZIP HOME PHONE RACE REFERRED BY: FIRST AND LAST NAME CELL PHONE EMPLOYER WORK STATUS - SELECT ONE WORK PHONE FULL TIME PART TIME RETIRED DISABLED PERSONAL PHYSICIAN NAME/PHONE # ( ) -- MARITAL STATUS S M W D SPOUSE'S NAME EMPLOYER SPOUSE WORK PHONE# PERSON TO CONTACT IN CASE OF EMERGENCY EMERGENCY CONTACT PHONE # **PLEASE COMPLETE ALL INSURANCE INFORMATION BELOW. DO NOT LEAVE BLANK.** Primary Insurance Insurance Company: Address City, State, ZIP Phone # ID# Secondary Insurance Insurance Company: Address City, State, ZIP Phone # ID# Group# Employer Name: Group# Employer Name: Policy holder NAME & DOB Policy holder NAME & DOB Policy holder SS# Policy holder SS# Payment Policy All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. The patient is responsible for all fees, regardless of insurance coverage. Payment is due when services are rendered unless other arrangements have been made in advance with our office. You agree to reimburse provider the feesof any collection agency, which may be based on a percentage at a maximum of 35% of the debt, which fee shall be added at the time of placement with the collection agency, and all costs, and expenses, including reasonable attorney's fees we incur in such collection efforts. Bariatric patients are subject to a $200 non refundable program fee. Insurance Authorization and Assignment I hereby authorize Dr. Anez to furnish information to insurance carriers (including Medicare/Medigap) concerning my illness and treatment and I hereby assign to the physician all payments for medical services rendered to myself or my dependents. I understand that I am responsible for the amount not covered by my insurance. PATIENT INITIALS: I understand that I will be responsible for a charge of $50.00 for missed appointments without at least 24 hours prior cancellation notice. I certify that the information I provided above is correct. All insufficient checks will incur a $25.00 return check fee. Date Signature I acknowledge that I have been offered a copy of the privacy notice of Dr. Anez. Copy Taken Copy Denied 1
2 DR. OSVALDO ANEZ 462 Herndon Parkway Suite 101, Herndon VA Tel: Fax: OFFICE POLICIES (Effective 1/1/2015) Office Hours are Monday-Thursday 9-5 with lunch from 12-1 and Friday Before the initial consultation it is the patient s responsibility to verify that their insurance policy does cover morbid obesity treatment. If Morbid Obesity coverage is not available, the patient will be billed the consultation fee. 2. Referrals are due at the time of each visit. It is the patient s responsibility to contact the insurance carrier to verify if a referral is needed. Patients without a referral will be rescheduled. 3. *PROGRAM FEE: A $ Non-Refundable Program/Administration Fee is required for Bariatric patients. The Program/Administrative fee covers all of the literature given to the patient in regards to our Bariatric services, Web Site services and all Surgical/Authorization paper work. This Program fee is due once we receive authorization from your insurance company & a surgery date is scheduled. This fee is not billable to the insurance companies. 4. Medicare patients receive an information packet that requires a signature. This is given to the patient if surgery is an option. 5. Returned check fee is $ Medical Requests are charged as followed: Base fee $15.00 and $.50 per page up to 50 pages, $.25 each page over 50 pages. Postage is additional. Fax requests require a medical release signed and it has to be fewer than 30 pages. 7. FMLA/Short-term disability; Patient s responsibility; Turn in all necessary forms to be completed by our Physician staff. Allow 1-2 weeks for form completion. When your forms are complete our office staff will notify you. Please include a stamped self-addressed envelope if you wish to receive them completed by mail. 8. AFTER HOURS FEE: There is a fee that will be assessed to the patient s account if non-urgent calls are placed after hours. 9. The patient is responsible for any collection fees incurred on past due balances. 10. Dr. Raphael Canadas is Dr. Anez s surgical assistant. His surgical fee is $800 for Bariatric Surgery (Roux en Y Gastric Bypass). Dr. Canadas will bill your insurance company his surgical fee after surgery. Please call your insurance company to verify if Dr. Canadas participates with your insurance plan or if you have out-of-network benefits that may cover his charges. If you DO NOT have coverage for the assistant surgeon, contact Dr Canadas office at (703) , prior to surgery, to discuss his fee and possible payment plans. Payment received by Dr. Canadas from your insurance company may be accepted as full payment for his assistant surgeon fees. 11. A $25 fee will be charged for all Work Related/Disability forms need to be filled out. I (patient) have read and do understand the entirety of the Office Policies. I agree to the terms and conditions of sections (1-8). I am fully aware of the Non-Refundable Program Fee and agree to all of the conditions that are noted in the policy given to me from the office staff at my initial consultation. Print Patient Name: Patient Signature: Date: / / 2
3 OSVALDO ANEZ MD. FACS. FICS. 462 Herndon Parkway, # 101, Herndon, Va Tel: Fax: SLEEP APNEA SCREENING AND ORDER FORM Patient Name: Sex: M F Date of Birth: SS#: Phone #: Home: Work: Cell: Tests: Requested Completed Diagnostic Polysomnogram (Sleep Study) Split Night (Combined Poly and CPAP/Bi-level Titration) CPAP/Bi-level Titration MSLT (Multiple Sleep Latency Test) Reason for Study: Past Medical History: Daytime Sleepiness with Apnea Cardiovascular Disease Daytime Sleepiness with Morbid Obesity Diabetes Morbid Obesity Pulmonary Disease Other Other Patient Questionnaire What is Sleep Apnea? Sleep apnea is the most common form of Sleep Disordered Breathing (SDB); a general term for a variety of breathing difficulties that occur during sleep. Sleep apnea is when a person experiences irregular breathing during sleep. Sleep patterns are disrupted resulting in daytime sleepiness and fatigue. Snoring is a warning sign of sleep apnea. You will hear loud snoring followed by periods of silence. There may be a loud snort or gasp as breathing restarts. This could happen hundreds of times per night. 1. I have been told that I snore. 2. I am overweight. 3. I have high blood pressure. 4. I tend to sweat excessively during my sleep. 5. I tend to fall asleep during in appropriate times. 6. I frequently awaken with headaches in the morning. 7. Others and/or I have noticed a recent change in my personality. 8. I am always sleepy during the day even if I slept throughout the night. 9. I have been told that I sleep restlessly. I am always tossing and turning. 10.I have been told that I stop breathing when I sleep without recollection. TOTAL CHECKED POSITIVE Scoring: If you have checked 3 or more boxes, you show symptoms of sleep apnea and should have a sleep study completed before surgery. Please call to schedule an appointment: Your PCP for referral Referring Physician: Dr. Anez Signature: Date: Fax Completed Form To: Dr. Anez s Office: 703/
4 OSVALDO ANEZ MD. FACS. FICS. 462 Herndon Pkwy Ste. # 101 Herndon, VA Phone FAX NOTICE OF PRIVACY PRACTICE - HIPAA This notice describes how medical information about you may be used and disclosed. Each time you visit this office, a record of this contact is made. This information serves as a Basis for planning your care and treatment, Means of communication among the many health professionals who contribute to your care, Legal document describing the care you received, Means by which you or a third-party payer can verify that services billed were actually provided, A source of data for education, research and planning, A source of information for public health officials charged with improving the health of the nation, A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve, A tool so that we know who we can contact with your personal information. PERMISSION TO CONTACT May we leave a message on your home answering machine? YES NO May we leave a message with your family members? YES NO May we call your work and speak with you or leave a message? YES NO May we call your cell phone? YES NO May we contact you by ? YES NO Date: Patient Name: Signature: 4
5 OSVALDO ANEZ MD. FACS. FICS. 462 Herndon Pkwy. Ste. # 101 Herndon, VA Tel: Fax: EXPECTATIONS Moving forward with your surgery can at times seem daunting. The information below will help you better prepare for your surgery. When you make the decision to have gastric bypass surgery, you will be responsible for a $200 program fee which is explained on the office policies. This fee is non-refundable. We will contact your insurance to verify that your plan covers weight loss surgery. If it is not a benefit, they will not cover the surgery or any of the related procedures/tests. If you have the surgery coverage, we will explain what the requirements are in order to get your surgery approved. If the insurance requires certain documentation or evaluations, we will not submit your authorization request until all applicable documentation is received by our office from you. Once your surgery procedure is approved, we will move forward on setting a surgery date. Surgery will not be scheduled sooner than 6 weeks from when we receive authorization. You will come back into the office for a 2 nd visit around 6 weeks before surgery. During this visit, you will speak with the Surgical Coordinator to discuss your pre-operative orders and confirm your surgery information. You will be scheduled for another office visit at this time to come back for your 3 rd office visit. The month before surgery will be a very busy time for you. We will refer you to work with the Bariatric Coordinator at INOVA Fair Oaks Hospital. This person is available to help you schedule your pre-operative testing. Be sure to keep your calendar accessible when scheduling your appointments. Being organized is very important during this time. Your pre-operative testing must be completed at least one to two weeks prior to surgery. You will return to the office two weeks before surgery to speak with Dr. Anez about the results of your tests, to discuss final questions and review pre- and post-operative instructions. After weight loss surgery, you will require frequent visits the first two years; after that, you will see us annually. It is your responsibility to stay current on your appointments. It is essential to have lab work done for each visit to ensure you are getting the proper nutrition and supplementation. You may obtain a lab slip from the office to have these tests done and the results will be available on your appointment day. Alternatively you may have labs drawn in the office (PPO policies only) the day of your visit and receive a call with the results. Best wishes on your new journey! Obesity Surgery Center Staff 5
6 OSVALDO ANEZ, M.D., F.A.C.S., F.I.C.S. 462 Herndon Parkway, Suite 101 Herndon, VA PHONE: FAX: PATIENT INSTRUCTIONS FOR PSYCHOLOGICAL EVALUATION Instructions: The guidelines below can assist you in obtaining the appropriate psychological evaluation needed prior to scheduling bariatric surgery. Bring this document with you to your appointment for psychological evaluation. I. WHO SHOULD PERFORM THE PSYCHOLOGICAL EVALUATION? A licensed psychiatrist (M.D.), licensed clinical psychologist (Ph.D.), or Masters-level social worker who has significant experience in psychological testing. II. WHAT SHOULD THE PSYCHOLOGICAL EVALUATION INCLUDE? An evaluation should include you completing an acceptable assessment tool such as the Minnesota Multiphasic Personality Inventory (MMPI), the Million Behavioral Inventory, or comparable assessment, which should be completed in a supervised setting. After completing the assessment, the psychiatrist or psychologist should engage in an evaluation session with you, using the assessment results. III. WHAT SHOULD THE PYSCHOLOGICAL REPORT INCLUDE? There is certain information which should be included in the report, at minimum: A. Patient Information: Name, Sex, Age, DOB, Address, Occupation B. Referring physician s name: If you are a member of HMO or PPO, this should be your primary care physician; otherwise, your surgeon is the referring physician. C. Reasons for Referral: Assessment of: Patient s motivation for gastric bypass or gastric banding surgery. The likelihood of post-operative compliance in all respects, including dietary restrictions and behavior modification. The likelihood of post-operative cooperation. D. Psychological History: Marital History Family History Personal History Weight history, including weight loss history History of addictive behaviors, including alcohol and drug abuse, anorexia and bulimia. ALL SUBSTANCE ABUSE HISTORY. E. Assessment: Results indicating which assessment tool was used and results F. Recommendation: Is the patient motivated to have surgery to correct the weight problem? Will the patient likely comply with post-operative requirements? Is additional psychological support needed? Is bariatric surgery advisable by the psychologist or psychiatrist? Does the patient fully understand the risks, alternatives, and possible complications associated with the proposed surgical procedure? *** I RECOMMEND THAT HE/SHE HAVE THE SURGERY. Please fax evaluations as soon as possible to (703)
7 OSVALDO ANEZ, MD, FACS. WELCOME Please fill out this form to the best of your knowledge. It will help us in your future care NAME: DOB: AGE: TODAY S DATE: RACE SEX Ht: Wt: BMI: IDEAL WT: Referring Physician: Phone: Fax: Have you ever been admitted to a psychiatric institution? Yes: No: If Yes, When: For how long: Reason: Do you feel you have a helpful support system around you? Yes No PAST HX & CO-MORBID CONDITIONS High Cholesterol Diabetes.. Pain in Joints/Multi Sites Acid Reflux.. High Triglycerides. Thyroid Problems.. Urinary Incontinence Peptic Ulcer Disease Hypertension... Gallstones Asthma.... Hiatal Hernia Heart Disease.. Breast Cancer Shortness of Breath. Anemia.. Ankle Swelling Uterine/Cervical CA.. Sleep Apnea. Blood Clot. Depression Arthritis Snoring. Other... PAST SURGERIES: MEDICATION: NAME DOSE/ FREQUENCY REASON ALLERGIES: FAMILY HISTORY: Obesity: (list relatives) Cancer: HTN: Diabetes: Heart Disease: SOCIAL HISTORY: Marital Status: ( M), (D), (S), (W). Children Occupation: Dress/Pant size: Do you smoke? Yes: No: If yes, how long, how many per day? Do you drink alcohol? Yes: No: If yes, what, how much, how long? Are you currently exercising? Yes: No: If yes, how often? Are you a Sweet Eater Yes: No: Snacks: Yes: No: Big Eater: Yes: No: PHYSICAL EXAM: CV: S1&S2 WNL. LUNGS: Clear. ABDOMEN: Soft, non-tender, no masses. BP PULSE EXTREMITIES: No edema, no signs of DVT. Required Consults/Tests Pre-op: Cardiac Clearance Psychological Clearance Pulmonary Clearance Sleep Study Hematology Endocrinology Medical (PCP) GI for EGD Other: 7
8 NON-SURGICAL EFFORTS AT WEIGHT LOSS DATES (range) PROGRAM/DIET/BEHAVIOR WT. LOST WT. REGAINED Protein diet (Atkin s, South Beach) Weight Watchers Over-Eaters Anonymous Jenny Craig Diet Pills/Shots MD. Supervised Curves Hypnosis Nutri-System Registered Dietitian Starvation Laxatives Liquid Fast i.e. Optifast Other The above is true and correct to the best of my knowledge. Patient Signature ASSESSMENT: MORBID OBESITY WITH COMPLICATIONS, RECOMMENDATIONS: Roux-en-Y Gastric Bypass, Robotic Sleeve Resection. (Diet, behavior modification imposed as well as potential complications and benefits were explained to the patient and he/she understood). Provider Name/ Signature Date 8
South Coast Medical Group Patient Registration
Patient South Coast Medical Group Patient Registration TODAY S Date:_ Last name First name Initial _ Social Security Number Date of Birth / / Sex Male Female Street Address City State Zip _ Phone Home
More informationName(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
More informationPATIENT INFORMATION NAME: DOB: / / AGE: FIRST MIDDLE LAST SS#: / / MALE/FEMALE RACE: MARITAL STATUS: S M W D
PATIENT INFORMATION Robert G. Marvin, M.D. The information provided in this form is vitally important in the planning of your surgical care. Omission of complete and accurate information to the physician
More informationMercy Metabolic and Bariatric Surgery Program Questionnaire
Mercy Metabolic and Bariatric Surgery Program Questionnaire Interested in bariatric surgery? Complete this form and return to us to be considered for evaluation: Sara Maduka, Mercy Metabolic and Bariatric
More informationID Policy Number Group Number Insurance Company Number. Secondary ID Policy Number Secondary Group Number Secondary Insurance Company Number
Weight Loss Institute of Arizona Dr. John DeBarros & Dr. Michael Orris Phone: (480) 829-6100 Facsimile: (480) 446-9475 Website: www.wliaz.com 1855 E. Southern Avenue, Tempe, AZ 85282 9305 W. Thomas Rd
More informationPATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
More informationHome Sleep Test (HST) Instructions
Home Sleep Test (HST) Instructions 1. Your physician has ordered an unattended home sleep test (HST) to diagnose or rule out sleep apnea. This test cannot diagnose any other sleep disorders. 2. This device
More informationPlease complete and return this form to be considered for evaluation
Office use only: MRN BMI Please complete and return this form to be considered for evaluation Name Date Age Date of Birth / / Sex M F Address City State Zip code Preferred Daytime Phone: ( ) - Do you have
More informationHealth History Form: Bariatric Surgery
Health History Form: Bariatric Surgery It is important that ThedaCare and Midwest Bariatric Solutions have a complete understanding of your health while preparing you for weight loss surgery. The bariatric
More informationPLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER
NORTHERN VIRGINIA CENTER FOR ARTHRITIS PLEASE PRINT PATIENT REGISTRATION Patient s Name: DOB: Sex: Address: PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER Home#( ) [
More informationNew Patient Information
New Patient Information First Name: Last Name: M.I.: Address: City: State: Zip Code: Mobile Phone: Home Phone: Email: Preferred method of communication: Mobile Phone Home Phone Email Date of Birth: Age:
More informationRaymond 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
More informationLake Psychological Services, LLC
Lake Psychological Services, LLC Welcome to Lake Psychological Services and thanks for choosing our office for your health care needs. Seeking treatment is not an easy decision and you may have questions
More informationPatient 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
More informationPATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
More informationWELCOME TO OUR OFFICE
PODIATRY / Dr. John Savidakis Jr. (727) 796-1490 WOUND CARE 2701 Park Drive, Suite #6 Fax: (727) 797-5611 Clearwater, FL 33763 WELCOME TO OUR OFFICE Today s Date : / / (Please use black ink.) PATIENT INFORMATION:
More informationBariatric Surgery Patient History Questionnaire
Bariatric Surgery Patient History Questionnaire Your appointment will be delayed if this form is incomplete please print legibly Personal Information Name Date SSN# (for insurance purposes) - - Date of
More informationBARIATRIC SURGERY PROGRAM APPLICATION Updated: 7/22/2016 Page 1 of 9
Updated: 7/22/2016 Page 1 of 9 Date: SELF Last Name: First: MI: Maiden: Address: City: State: Zip: Home #: Cell #: Work #: Date of Birth: SSN#: Gender: Male Female Marital Status: Married Divorced Widowed
More informationArizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305
Patient Information Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305 Home Phone: Cell Phone: Last Name: First Name: MI Mailing Address: APT City/State/Zip Sex: Male Female Birthdate:
More informationAddress (if different from above):
Lee H. Baker, DDS 1243 Augusta West Pkwy Augusta, GA 30909 (706) 855-8989-Phone (706) 855-0321-Fax www.drleebaker.com Welcome to our practice! In order to know you and your child better, please complete
More informationADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG DATE SOC. SEC. NUMBER FULL NAME DATE OF BIRTH ADDRESS: STREET TOWN STATE ZIP PHONE: HOME WORK CELL EMPLOYER OCCUPATION ADDRESS
More informationSeminar Information Page
OFFICE USE ONLY Height, Weight & BMI Insurance Primary Care Phys. Medical Problems Surgical History Med List & Dosage Allergies & Fam Hist. CDS (city, washoe, wcsd or reno diocese) OFFICE USE ONLY Pt #
More informationWelcome to the Center for Surgical and Medical Weight Loss. Thank you for choosing our Center at Saint Thomas for your weight loss journey.
Welcome to the Center for Surgical and Medical Weight Loss. Thank you for choosing our Center at Saint Thomas for your weight loss journey. Once your initial appointment has been scheduled, you will receive
More informationPATIENT HEALTH HISTORY FORM:
PATIENT HEALTH HISTORY FORM: It is very important to know your detailed medical history information to assess your health. Obesity and its associated diseases and risk factors increase mortality and surgical
More informationNew Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
More informationPATIENT REGISTRATION
PATIENT REGISTRATION "Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying ** First Name: Last Name: Middle Initial: Address: Apt #: City: State: Zip: Date of Birth:
More informationPatient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715
Patient Packet Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715 Welcome Thank you for your interest in SSM Health Weight Management Services. Please complete the enclosed questionnaire
More informationHEALTH HISTORY QUESTIONNAIRE
HEALTH HISTORY QUESTIONNAIRE Date Patient Name Date of Birth Age Daytime phone ( ) Email _ Other phone ( ) How did you hear about us? My doctor Yellow pages News ad Radio/TV Friend/family Web site Other
More informationOffice Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
More informationCHISHOLM TRAIL ALLERGY AND ASTHMA PHONE (817) /FAX (817) DUTCH BRANCH ROAD, SUITE 200, FORT WORTH, TX
Today s Date: New Patient Registration and Medical History Patient Name: Nick Name: Address: Apt/Lot: City: State: Zip Code: Home Phone: Cell phone: Email: Is it ok to leave messages on the phone numbers
More informationBARIATRIC PROGRAM PATIENT HEALTH HISTORY QUESTIONNAIRE (PLEASE PRINT CLEARLY)
BARIATRIC PROGRAM PERSONAL INFORMATION PATIENT HEALTH HISTORY QUESTIONNAIRE (PLEASE PRINT CLEARLY) Name: Date: Sponsor s SSN# - - Date of Birth: Age: Mailing Address: City: State: Zip: Mobile Phone: Home
More informationHEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
More informationPATIENT 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:
More informationHEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social
More informationGARDEN STATE SLEEP CENTER REGISTRATION FORM PATIENT INFORMATION:
GARDEN STATE SLEEP CENTER REGISTRATION FORM (Please Print) Today s Date: Primary Care Physician: PATIENT INFORMATION: Last Name: First: Middle: Mr. Miss Dr. Mrs. Ms. Marital Status (Please check one) Single
More informationWelcome to Saratoga Ophthalmology!
Amjad M. Hammad, MD, MBA Salman J. Yousuf, DO The Center for Vitreo-Retinal Surgery Charles H. Rheeman, MD Gregory B. Krohel, MD The Center for Oculoplastics & Neuro-Ophthalmology Kamran I. Chaudhri, MD
More informationNutrition Initial Assessment
Nutrition Initial Assessment Client Name: Referring Physician: Home Phone: Home Address: Date: Email: What are the goals that you are trying to achieve with your initial appointment? Past Medical History:
More informationNew Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
More informationPatient 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
More informationNutrition Packet INFORMATION FOR THE DAY OF YOUR APPOINTMENT
Nutrition Packet Enclosed is a packet of information for you to fill out and bring with you to your appointment. But first, a few important details before we meet: INFORMATION FOR THE DAY OF YOUR APPOINTMENT
More informationSleep Medicine Associates
Date: Patient Name: DOB: Patient Height: _ Weight: _ lbs Referring Physician: Neck Size: Main Sleep Problems: 1. My main sleep complaint is: Trouble Sleeping at night Sleepy during the day Unusual behavior
More informationNEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
More informationNEW PATIENT PAPERWORK
NEW PATIENT PAPERWORK Welcome! Please fill out the necessary paperwork provided. It is our pleasure to serve you and your family. How did you find out about us? If It was a friend or doctor, please list
More informationWILSON HEALTH WEIGHT AND WELLNESS HEALTH HISTORY FORM
Please complete and bring to your first appointment WILSON HEALTH WEIGHT AND WELLNESS HEALTH HISTORY FORM Name: Date of Birth: I certify that all the information I provide is true and complete to the best
More informationTell Us About Your Child
5C Medical Park Drive Pomona, NY 10970 (845) 414-9626 drsmith@smithslittlesmiles.com www.smithslittlesmiles.com Marita Smith, DDS Board Certified Pediatric Dentistry We are thrilled to welcome you and
More informationDirections to Whole Woman Health - located in the NW Des Moines/Beaverdale area:
Whole Woman Health Patient Registration Form Welcome New Patient! We are pleased you have chosen Whole Woman Health. Below is your registration form as well as Medical History and Assessment forms. Please
More informationWelcome to South 40 Dental! Tell Us About Yourself
Welcome to South 40 Dental! Tell Us About Yourself Name: Last First MI Title Preferred Name: Male Female Parent/Guardian Name if Under 18 Years Old: Address: City Prov. Postal Code Date of Birth (day)
More informationPATIENT SIGNATURE: DOB: Date:
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received a copy of CPP s Notice of Privacy Practices. The Notice
More informationApplication for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to
More informationBariatric Patient Registration / /
Page 1 of 7 Bariatric Patient Registration / / Today s Date Please Print Clearly Patient s First Name Middle last Current Height / Weight Mailing Address City State Zip Home Phone Work Phone Cell /Pager
More informationPatient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:
Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Patient Information Patient Name: DOB: Last First M.I. Home Address: City:_ State:
More informationINITIAL EVALUATION FORM
INITIAL EVALUATION FORM The following information is very important to your health. It will help us to give you the best possible medical/surgical care. Please take the time to complete this questionnaire.
More informationWeight Loss Surgery Program Application
Weight Loss Surgery Shaded area for office use only SELF LAST NAME FIRST MI MAIDEN CITY STATE ZIP SOCIAL SECURITY NUMBER DATE OF BIRTH AGE MALE FEMALE MARRIED DIVORCED WIDOWED SEPARATED NEVER MARRIED RACE:
More informationLast Name First Name MI SS# DOB. Address. City State Zip. Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell)
39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA 19104 215-662-9775 823 South 9 th Street, 1 st Floor Philadelphia, PA 19147 267-239-2725 Last Name First Name MI SS#
More informationAccess Endodontics Marat Tselnik, DDS -PRACTICE LIMITED TO ENDODONTICS-
Access Endodontics Marat Tselnik, DDS -PRACTICE LIMITED TO ENDODONTICS- REFERRED BY: TODAY S DATE: PATIENT NAME HOME PHONE (LAST) (FIRST) (MIDDLE) E-MAIL CELL PHONE HOME ADDRESS (STREET) (CITY) (STATE)
More informationTelephone: Fax:
PATIENT AUTHORIZATION TO RELEASE MEDICAL RECORDS AND DEMOGRAPHIC INFORMATION DATE: SS #: PATIENT NAME: BIRTHDATE: / / PATIENT ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE #: CELL PHONE #: REFERRING PHYSICIAN
More informationPlease call at least 24 hours in advance to cancel any appointment. You may be charged a $20.00 fee for a no call/ no show office visit.
Welcome to the Sleep Disorders Center at Kettering Medical Center. We would like to ask that you fill out the following information before you arrive to the sleep clinic on your scheduled appointment.
More informationPeaceHealth Southwest Weight Loss Surgery Process
PHSW Weight Loss Surgery Center PHSW Specialty Clinic 8716 E Mill Plain Blvd. Vancouver, WA 98664 Phone (360) 514-4265 Fax (360)514-4233 PeaceHealth Southwest Weight Loss Surgery Process What is the next
More informationVan Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
More informationPatient Registration Form Personal Information Name (Last, First, M.I.) Date
Patient Registration Form Personal Information Name (Last, First, M.I.) Date Birthdate Soc. Security # - - Male Female Single Married Divorced Widowed Race American Indian Asian African American Pacific
More informationAcknowledgement of receipt of notice of privacy practices
Acknowledgement of receipt of notice of privacy practices NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a Notice of Privacy Practices from Kettering Physician Network (dba Kettering Cancer
More informationName: Age: DOB: / / City Zip Wk Tel: ( ) Cell: ( ) Referring Physician: How did you hear about Dr. Ordon?
Andrew P. Ordon, M.D., F.A.C.S. 465 N. Roxbury Drive, Suite 1001, Beverly Hills, CA 90210 Tel: (310) 248-6250 w Fax: (310) 861-1529 www.drordon.com Date: Name: Age: DOB: / / Address: Home Tel: ( ) City
More informationEYE ASSOCIATES OF MONMOUTH, LLC
EYE ASSOCIATES OF MONMOUTH, LLC In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. This is very important information. Please
More informationFINANCIAL POLICY STATEMENT
FINANCIAL POLICY STATEMENT Southern Nassau Physical Therapy, Western Nassau Physical Therapy and Seaside Physical Therapy/DBA Peak Performance Physical Therapy will bill your insurance carrier as a courtesy
More informationEmergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name
TELL US ABOUT YOU (please print) First MI Last Address 1 Address 2 CITY ST ZIP COUNTRY E-mail Opt out of providing E-mail Address Language Preference SSN - - DOB / / Driver s License # ST Phone 1 CELL
More informationBrunswick Pulmonary and Sleep Medicine Lawrence Davanzo, DO, FCCP 49 Veronica Ave, Somerset, NJ Phone# Fax#
REGISTRATION FORM (Please Print) Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid If not, what is
More informationSPORTS AND SPINE PHYSICAL THERAPY, INC. PATIENT MEDICAL HISTORY
SPORTS AND SPINE PHYSICAL THERAPY, INC. PATIENT MEDICAL HISTORY Name: Referring Physician: How did you hear about Sports and Spine Physical Therapy? First date of onset of pain: Have you had surgery for
More informationPATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN
More informationOur office is located at 2030 Drew Street, Clearwater FL, We are on Drew Street, in between N.E Old Coachman Road and Hercules Avenue.
Dear New Patient, Thank you for choosing Dennis M. Lox, M.D to participate in your healthcare. We realize that you could have chosen any other office, so we are honored that you have chosen us. While Dr.
More informationLast: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
More information\ NSMI. The National Sports Medicine InstJtute
~ \ NSMI The National Sports Medicine InstJtute 19455 Deerfield Avenue Su ite 3 12 Lansdowne, Virgin ia 20 I76 24430 Stone Spring Blvd, Suite 250, Dulles, Virginia 20166 Patient Information: Last Name:
More informationSports and Spine Physical Therapy
Sports and Spine Physical Therapy PATIENT MEDICAL HISTORY Name: Referring Physician: How did you hear about Sports & Spine Physical Therapy? First date of pain: Have you had surgery for this injury? Yes
More informationDATE: Dear Mr./Mrs./Ms., location.
Consultants in Pain Medicine, P.A. 5368 Fredericksburg Road Legacy Oaks Building C Ste. 210 San Antonio, Texas 78229 Phone (210) 546-1470 Fax (210) 546-1479 DATE: Dear Mr./Mrs./Ms., You have been referred
More informationNew Patient Information
Patient's Street Address: Home Phone: Cell Phone: of Birth: / / New Patient Information State: Name of Person Responsible for This Account: E-Mail Address: Zip Code: Work Phone: SSN: Do You Have Dental
More informationPatient Information Form
Patient Information Form Patient Name: (Last) (First) (MI) Name you prefer to be called: Mailing address: City: State: Zip: Best daytime phone: May we leave a message there? Yes No Alternate phone number:
More informationPLEASE NOTE: This file must be saved to your desktop before and after completing!
PATIENT INFORMATION PLEASE NOTE: This file must be saved to your desktop before and after completing! Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number
More informationPatient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
More informationGordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
More informationALLERGIES (food,latex,other)
MEDICATION LIST NAME: DOB: Main Phone: (CELL or HOME) Initials Consent to Import Medication History I give Dr. Heniff consent to import my medication history as provided by SureScripts. ALLERGIES (food,latex,other)
More informationPATIENT INTAKE FORM Health & Wellness
PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
More informationWelcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
More informationSLEEP CENTER OF KENTUCKIANA 7926 Preston Hwy. Suite 200 Louisville, KY Tel: (502) Fax: (866)
Patient Information First Name MI Last Name Age Date of Birth Social Security # Work Sex Male Female Home Phone Cell Phone Next of Kin Relation Phone Number Address City State Zip Code Employer Employer
More informationClinical Genetics Service
Clinical Genetics Service Helping You and Your Family Reduce Your Risk Your appointment is at AM/PM North Office Location 7714 Conner Road Suite 107 Knoxville, TN 37849 West Office Location Tennova Turkey
More informationABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
More informationPro Active Physical Therapy & Sports Medicine
Pro Active Physical Therapy & Sports Medicine Consent and Statement of Financial Responsibility 1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other
More informationINFORMATION PACKET INITIAL APPOINTMENT
FIRST APPOINTMENT CHECKLIST Please bring the following items to your first appointment. Please bring the following documents to your first visit: Completed Patient Questionnaire (attached to this document).
More informationTop Tier. Medical Breast Specialist, P.C.
Karen S. Barbosa, D.O. Board Certified, Fellowship Trained Breast Surgeon Top Tier Medical Breast Specialist, P.C. 80 Maple Avenue Smithtown, NY 11787 Office: 631.870.8721 Fax: 631.870.8722 Office Visit
More informationOffice Location: Media Glen Mills Havertown Date of Evaluation. Last Name, First, Address. City State Zip. Home Phone: ( ) -- Work Phone:( ) -- SS#
Pain Relief and Physical Therapy 203 E Baltimore Pike, Suite 2 101 W. Eagle Road, Suite 1 Media, PA 19063 Havertown, PA 19083 Phone: 610-565-0670 Phone: 610-789-9887 Fax: 610-565-7706 Fax: 610-789-9883
More informationNew You Weight Management Program
New You Weight Management Program Initial Evaluation Form (All questions MUST be answered to be considered for the program. Patients are NOT chosen on a first-come, first- served basis. The information
More informationBariatric Surgery Program Patient Health Questionnaire. This form must be completed and returned at your Bariatric Education Class.
The Center for Weight Loss Surgery 111 Osborne Street Danbury, CT, 06810 203.739.7131 / 203.739.1669 fax Bariatric Surgery Program Patient Health Questionnaire Name: DOB: Please answer the following questions
More informationPatient History Form: Bariatric Surgery Page 1 of 9
Date you attended Informational Session / / How did you hear about us? Radio Newspaper TV Word of Mouth Magazine Referred by Dr. Other: Name: Age: Date of Birth: / / Occupation: Gender: Male/Female Address:
More informationMarga F. Massey, MD, FACS Getting to Know You! Patient Information Form
Marga F. Massey, MD, FACS Getting to Know You! Patient Information Form Date: Patient Name: Age: Birthdate: Weight: Height: Breast Size: _ SSN: Home Phone: Cell: Address: City: _ State: Zip: Email: Primary
More informationNebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
More informationWEIGHT LOSS PATIENT INFORMATION RECORD
WEIGHT LOSS PATIENT INFORMATION RECORD PLEASE BRING THIS COMPLETED FORM TO YOUR APPOINTMENT Date: / / Last Name: First: MI: Date of Birth: / / Sex: Age: Home Phone: ( ) Mobile Phone: ( ) Address: City:
More informationChiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
More informationYour Body. Your Life. Start Today. Patient Packet
Your Body. Your Life. Start Today. Patient Packet ssmweightloss@ssmhealth.com Thank you for your interest in SSM Health Weight Management Services. Completing this application packet is the first-step
More informationFamily First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
More informationNew Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
More informationEa Medical Weight Loss Services Solutions for permanent weight loss PATIENT HISTORY. When did you first become overweight? (Your age then) or Year
PATIENT HISTORY Name: Age: Date: When did you first become overweight? (Your age then) or Year How did your weight gain start? Describe any circumstances: What do you think is the cause of your weight
More information