WELCOME TO OUR CLINIC!
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1 ERIN L. HOLLOMAN, M.D. ADAM G. DE LA GARZA, M.D. DIANA A. TAMBOLI, M.D. STERLING S. BAKER, M.D. WELCOME TO OUR CLINIC! Placing your trust in our physicians and staff is a very big decision and we would like to say thank you for choosing us. We would like to make sure that everything goes smoothly for you during each of your visits, so please ask us if you have any questions, comments or need further information or clarification on any products or services. For your convenience, we have attached all forms that you will need to complete prior to your visit. We are dedicated to patient care, education and satisfaction. We are looking forward to meeting you! THANK YOU AGAIN FOR PLACING YOUR TRUST WITH US. Sincerely, Staff of the Oculoplastic Surgeons of Oklahoma DR. HOLLOMAN DR. DE LA GARZA DR. TAMBOLI DR. BAKER N. MAY AVENUE, EDMOND, OK PHONE FAX OCULOSURGEONS.COM OCULOPLASTIC SURGEONS OF OKLAHOMA, PLLC
2 FACILITY LOCATIONS FOR APPOINTMENTS OUR OFFICE N. May Avenue Edmond, OK FOR OUTPATIENT SURGERY SUMMIT MEDICAL CENTER N. Portland Avenue, Suite 100 Oklahoma City, OK N.W. 164TH ST. 74 FOR APPOINTMENTS OCULOPLASTIC SURGEONS OF OKLAHOMA N.W. 150TH ST. N. MACARTHUR BLVD. N. PORTLAND AVE. 74 FOR OUTPATIENT SURGERY SUMMIT MEDICAL CENTER N. MAY AVE. N. PENNSYLVANIA AVE. W. MEMORIAL RD. JOHN KILPATRICK TURNPIKE JOHN KILPATRICK TURNPIKE OCULOPLASTIC SURGEONS OF OKLAHOMA, PLLC
3 APPOINTMENT CHECKLIST Please arrive 20 minutes early to your appointment. Bring all included forms in this packet. Be sure to have your photo id and insurance cards READY upon arriving to expedite your wait time. Please bring ANY and ALL medication, allergy, and surgery lists you may have to your appointment. If you need to reschedule or cancel your appointment, kindly give our office a 24 notice. You can reach us at if you have any questions. WE LOOK FORWARD TO SEEING YOU!
4 16315 N. MAY AVE EDMOND, OK Patient Information as of (Please Print Legibly & Fill In or Correct All Fields) (enter today s date) Patient Name Last First Middle Home Phone Cell Phone Any restriction for contacting you? Contact Restrictions Age Birthdate SS# Sex Male Female Marital Status Single Married Patient s Employer Occupation Work Phone Ext. Is it okay to call at work? Emergency Contact (Not in your household) Relationship to patient Home Phone Work Phone Other Phone I understand that office visit charges are payable on the day service is rendered. I authorize Dr. «Doctor_Last_Name» to bill my insurance company. Regardless of insurance coverage, I am responsible for all bills being paid in a timely manner. I understand that my contract is between Dr. «Doctor_Last_Name» and myself. You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or s, using any address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. Please list any person(s) we are permitted to release private health information regarding your care and/or billing. Name Relationship Phone Name Relationship Phone I have read this disclosure and agree that I may be contacted as described above. Signature Date
5 HEALTH HISTORY Date Patient Name Weight Height Have you experienced? YES NO If yes, please explain briefly Sudden Onset of Weight Loss or Gain Increased Fatigue Difficulty with your Vision Difficulty Swallowing Chest Pains Skin Rashes for no Apparent Reason Bruise Easily or Take Blood Thinners Use Tobacco Products Consume Alcoholic Beverages Heart Arrhythmia? Hypertension? Heart Valve Problems or Pacemaker Do you have a Defibrillator Asthma, Emphysema, Sleep Apnea Acid Reflux Disease Urinary Tract Infections, Kidney Stones Cancer, including Skin Cancer Arthritis: Rheumatoid/Osteo Bleeding Disorder Diabetes Thyroid Disease, other Chronic Conditions Problems with Anesthesia FAMILY HISTORY: Does any member of your immediate family have? If so, who? Arthritis? Glaucoma? Cancer? Macular degeneration? Heart disease? Retinal detachment? High Blood Pressure? Stroke/TIA? Diabetes? Anesthesia complications? Past Surgeries, Trauma or Hospitalizations Current Medications:(including aspirin, herbs and supplements) Allergies or sensitivity to medicines; Drug: Reaction: Drug: Reaction: Drug: Reaction: Drug: Reaction: Pharm: Phone#:
6 FACIAL SKIN HISTORY Name Last First Middle Home Phone Business Phone Age Referred by What problem are you consulting for? Cosmetic facial surgery Sun spots Wrinkles Enlarged blood vessels Other What skin care products do you currently use? (Cleanser) (Moisturizer) (Anti-aging) (Sunblock SPF daily) How long have you noticed this problem? Have you ever been treated for this problem If yes when? By what method? Are you currently taking medication for your skin problems? Are you pregnant, nursing or planning a pregnancy soon? Do you have a history of keloid scarring? Have you ever taken Accutane? Do you have any skin related allergies? If yes, please specify Do you wear contact lenses? Do you have a history of cold sores or fever blisters? Mark your skin type (when exposed to the sun for about 1 hour with no protection) Always burns, never tans (almost albino skin) Usually burns Sometimes burns, sometimes tans Always tans Rarely burns Never burns When were you last exposed to the sun or tanning booth? Do you use chemical suntanning lotions? Are you planning a holiday in the sun? Have you ever had skin resurfacing or rejuvenation or chemical peels? If yes, when and what kind? Have you ever had treatments for pigmented lesions? Prior treatment (if any) Have you ever smoked or used tobacco? Do you use tobacco now? If yes, How much? pkg. per day Do you use nicotine supplements now? (for example: Nicoban chewing gum) If you do not use tobacco products now, when di you quit? months/years ago Do you consume alcohol? Patient Signature Date
7 16315 N. MAY AVE EDMOND, OK ERIN L. HOLLOMAN, M.D. ADAM G. DE LA GARZA, M.D. STERLING BAKER, M.D. DIANA TAMBOLI, M.D. PHOTO USE RELEASE FORM I,, hereby grant and authorize Oculoplastic Surgeons of Oklahoma, PLLC the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of to be used in and/or for presentations, legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of Oculoplastic Surgeons of Oklahoma, PLLC and will not be returned. I hereby hold harmless, and release Oculoplastic Surgeons of Oklahoma, PLLC from all liability petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate. If the person signing is under the age of consent, then this release must be signed by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual. Signature Date
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Patient Registration First name: Last name: Patient is: Responsible party Child Address: City: State: Zip: Home phone Cell phone: Work phone: Sex: Male Female Birth date: Material status: Single Married
(FIRST) (MIDDLE) (LAST) STREET: CITY: STATE: ZIP CODE:
PATIENT INFORMATION EMAIL: MARITAL STATUS: [ ]MARRIED [ ]SINGLE [ ]DIVORCED [ ]WIDOWED NAME: (FIRST) (MIDDLE) (LAST) STREET: CITY: STATE: ZIP CODE: DOB: PHONE: [ ]Home [ ]Work [ ]Cell PHONE: [ ]Home [
ADVANCED SPINE HEALTH AND WELLNESS CENTER DR. PAUL BACON
ADVANCED SPINE HEALTH AND WELLNESS CENTER DR. PAUL BACON Patient Name: Address: City: State: Zip Code: H. Phone: W. Phone: Cell Phone: Email Address: Sex M F Marital Status M S D W Date of Birth Age Social
Lake Forest Dental. Patient Information
Lake Forest Dental We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have any questions we ll be glad to help you. We look forward to working
NEW 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
Lake Forest Dental. Patient Information
Lake Forest Dental We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have any questions we ll be glad to help you. We look forward to working
FRAME CHIROPRACTIC South Price Road, Suite D-110 Tempe, Arizona Phone: Fax:
3330 South Price Road, Suite D-110 Tempe, Arizona 85282 Phone: 480.345.2080 Fax: 480.345.2199 W E L C O M E ABOUT YOU (please print) Today s Date: Patient Name: DOB: Age: SS#: Mailing Address: City: State:
Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )
Today's : Patient Information First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Email: Work Phone: ( ) Primary Care Physican: Cell Phone: (
Steven J. Smith Kingwood Dr., BLDG. 6 Kingwood, Texas 77339
97 Kingwood Dr., BLDG. 6 Kingwood, Texas 779 MEDICAL HISTORY (please print) LAST NAME FIRST NAME M F DOB REASON FOR VISIT MEDICATIONS Please list all the medications you are currently taking, including
PATIENT INFORMATION. RESPONSIBLE PARTY (If Different from Patient) POLICY HOLDER INFORMATION (If Different from Patient)
PATIENT INFORMATION Today s Date: Patient s Last Name: First: M.I. Mailing Address: City: State: Zip: Home Phone: ( ) Cell: ( ) Work: ( ) Date of Birth: / / Age: Sex: SSN: Driver s License #: Marital Status:
NOTICE TO OUR PATIENTS
SMG Chestnut Street, SMG Elm Street, SMG Mancos Valley, Southwest Walk-In Care, Southwest School-Based Health Center, SMG Market Street, SMG Orthopedics, SMG Pulmonary and Sleep Medicine, SMG General Surgery,
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
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
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
Sincerely, Dr. Justin & Woodbury Spine Staff
Welcome to our office! We are sure that you will be provided the most appropriate and professional chiropractic care possible. Our most important goal is the constant improvement and maintenance of your
Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION
Home Address: Home Telephone: CHILD 1 First Name: Last Name: School: Age: Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION PATIENT INFORMATION Birthday: / / Sex:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address: Whom may we thank for referring you to us? Names of
HEADACHE 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:
General Information: (Circle One) (Circle One) Primary Insured's Information Skip if you are primary
General Information: First Name: Middle Initial: Last Name: Suffix: Called Name: Street Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: Marital Status: