Asthma & Allergy Clinic REGISTRATION FORM
|
|
- Vivian Farmer
- 5 years ago
- Views:
Transcription
1 Asthma & Allergy Clinic REGISTRATION FORM 1 Today s date: Primary Care Provider: Referred by: PATIENT INFORMATION Patient s last name: First name: Middle: Marital status: married divorced widowed separated single Date of birth: Age Sex: M F Address: City: State: Zip code: Social Security #: Home phone: Cell phone: Work phone: Employer: address: Preferred Pharmacy with phone # Spouse s name: Spouse s SS #: Spouse s cell phone: RESPONSIBLE PARTY AND INSURANCE INFORMATION (PLEASE PROVIDE YOUR INSURANCE CARD TO THE RECEPTIONIST) Person responsible for the bill: Relationship to the patient: Address, if different: Telephone number: Please indicate primary insurance: Subscriber: Subscriber SS#: Policy #: Group #: Co-payment for Specialist: Patient s relationship to the subscriber: List secondary payer information: Subscriber: Subscriber SS#: Policy # Group #: Relationship to subscriber: IN CASE OF EMERGENCY Emergency contact name: Relationship to patient: Home phone: Cell phone: I authorize Asthma & Allergy Clinic and/or its collection agents to release any medical information necessary to be submitted to my health insurance carrier for claim processing and adjudication. I grant assignment of benefits to Asthma & Allergy Clinic so payment can be made directly to my provider of Asthma & Allergy Clinic. I also understand that I am financially responsible for any balances not paid by my insurance and finance charges may be applied for charges not paid according to the policies of Asthma & Allergy Clinic or its collection agents. I take full responsibility that the information provided on this registration record is accurate and complete and that I have followed my plans policies regarding authorizations, referrals, pre-certifications or pre-admission authorizations prior to services rendered. I acknowledge that I will be responsible for a $35 no-show fee should I not cancel my appointment 24-hours in advance of my appointment and a $35 returned check fee that will be added to my account and only payable in cash or money order. I acknowledge that I was offered a copy of the HIPAA Notification of Privacy Practices and given an opportunity to ask questions about the information provided. I have read and agree to the terms of the practices financial policies and I certify that I understand the contents of this form. I hereby authorize Asthma & Allergy Clinic to request and use your prescription medication history from other healthcare providers and/or third party payer pharmacy benefits for treatment purposes. I agree to allow Asthma & Allergy Clinic to communicate appointment reminders via my cell phone texting capabilities and/or to leave recording appointment reminders on my home or cell phone numbers. I hereby consent to treatment by Asthma & Allergy Clinic and/or affiliated medical staff members on behalf of my minor child/children and me including stepchildren. I understand that during treatment, the possibility exists for health care workers to become directly exposed to the individual s blood or body fluids. The law authorized the health care providers to test patients for HIV antibodies, deemed consent, when the health care provider is exposed to the body fluids of a patient. In the event of exposure, I understand that I will be deemed to have consented to testing and consent to release test results to the health care worker who may have been exposed. Prior to testing, I will be informed and given the opportunity to ask questions. Patient(s) name please print Date of birth Patient(s) name please print Date of birth Signature of patient/legal guardian Date: Relationship to patient(s)
2 The Asthma and Allergy Clinic Dr. John R. Sweeney Jr. Md FAAAAI Thamiris V. Palacios-Kibler, DO FAAAAI Alice Wilkins-Bryson, RN MSN FNP 2 Suffolk Office- Phone # (757) Fax # (757) Portsmouth Office- Phone # (757) Fax # (757) *Please plan on spending at least 2 hours at this first visit. Dear Future Allergy Patient: We are looking forward to seeing you soon! I am enclosing some information about our medical practice. I am also enclosing a medical questionnaire which we ask all our new patients to fill out. It is very important that you complete these forms prior to your appointment and bring them with you when you arrive. This information will help our specialists diagnose and formulate a treatment plan for your allergies. In order to do allergy testing, we ask all our patients to please stop taking antihistamines for 3 to 7 days prior to their scheduled appointment. Allergy testing can be an important tool in making a definitive diagnosis as to the cause of your allergies. If antihistamines are in your body s system, the test results may give us a false reading. If you have any questions about any of your medications, please give us a call and one of our nurses will be happy to assist you. Please plan to arrive approximately 15 minutes early for your appointment to allow time for checking-in and new patient processing. Thank you for choosing The Allergy & Asthma Clinic. We will do our very best to help you with your allergies. Sincerely, Your Asthma and Allergy Care Team! Please note our Cancellation Policy, as follows: Notice of cancellation or rescheduling is required no less than 24 hours prior to any scheduled appointment to allow us to give the appointment time to another patient. No-shows, with less than 24 hours notice will be subject to a $35.00 charge.
3 The Asthma and Allergy Clinic Dr. John R. Sweeney Dr. Thamiris V. Palacios-Kibler Alice Wilkins-Bryson, FNP 3 Payment Policy Thank You for choosing our practice. We are committed to providing you with quality and affordable healthcare. Below is information to answer frequently asked questions regarding patient and insurance responsibility for services rendered. Please read it, ask us any questions that you may have and sign in the space provided. A copy will be provided to you upon request. Thanks so much for being our patient. PAYMENTS ARE DUE AT THE TIME OF SERVICE UNLESS PAYMENT ARRANGEMENTS HAVE BEEN REQUESTED AND APPROVED IN ADVANCE. YOU ARE EXPECTED TO PAY ACCORDING TO THE ARRANGEMENT. Insurance We participate with most insurance plans. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. You or insurance benefit is a contract between you and your insurance company. Referrals If you have an insurance plan which requires a referral, you will need a referral authorization from your primary care physician/ pediatrician. If we have not received a referral prior to your arrival at the office, we have a telephone for you to use to call your primary care /pediatrician physician to obtain it. If you are unable to obtain the referral at that time, you will be rescheduled. Co- payments and Deductible All co-payments- Deductible & Co-insurance must be paid at the time of service. This arrangement is part of your contract with your insurance company and we are contractually obligated to collect them. Proof of Insurance All patients must complete our patient information form before seeing our providers. We must obtain a copy of your driver s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Coverage Changes If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. Methods of Payment We accept payment by cash, check, Visa, MasterCard, and Discover. Patient Statements If you have unpaid balance you will receive a statement by mail every two weeks. The statement amount is due and payable when the statement is issued, and past due if not paid upon receipt. Balances over 90 days will be turned over to an attorney or collection agency for collections. All payments made go to the oldest outstanding balance. No Show Fee Please cancel/reschedule your visits with 24-hours notice. At our discretion, a fee of $35.00 will be charged for a missed appointment. Collection Fees: Balances that have not had a payment made within 90 days will be turned over to collections. Guarantor will be responsible to pay all costs of collections including reasonable interest, reasonable attorney s fees and reasonable collection agency fees not to exceed 33 1/3%. Patient s Name: Responsible Party: Signature: Date: Office Use: Received By: Date:
4 The Asthma and Allergy Clinic Dr. John R. Sweeney Jr. MD FAAAAI Thamiris V. Palacios-Kibler, DO Alice Wilkins-Bryson, RN MSN FNP 4 Name DOB Date How would you like to be addressed? Mr./Mrs./Ms./Dr. How did you hear about us? Primary Care Physician: Please, describe the reason for the visit today: Referring Physician? Which pharmacy do you use? Phone # HISTORY OF PRESENT ILLNESS: Do you have upper airway symptoms, that you suspect may be caused by allergies? Yes No If Yes, please circle your symptoms: Stuffy Nose: Itchy mouth/ears Loss of Smell Mouth Breathing Runny Nose: Frequent Sneezing Itchy/red/watery eyes Bad Breath Post Nasal drip: Nose Bleeds Difficulty Hearing Loss of Taste Throat Clearing: Snoring Sore Throat Voice Change Itchy Nose: Nasal Polyps Phlegm Nasal congestion Other Symptoms: How long have you had symptoms? What time of the day is worse? AM/PM Worst season of the year: Are symptoms year long? Do you have symptoms when exposed to any of the following triggers? (Please, circle all that apply) Grasses Trees Weeds Molds House Dust Cats Dogs Exercise Windy Temperature changes Stress Smog Smoke Fragrances Chemicals Menstrual Period Strong Odors Alcoholic beverages Spicy Foods Cold Days Have you ever had skin testing? Yes No If yes, how long ago? Have you ever been on allergy injections (desensitization)? Yes No If yes, how long? Have you had sinus infections in the past? Yes No If yes, how often? Have you had an X-ray or CT scan of your sinuses? Yes No If yes, when? ASTHMA Have you ever been diagnosed with Asthma? YES NO If YES, year diagnosed If NO, have you or are you experiencing any of these symptoms? Please, Circle any applicable symptoms Shortness of breath at rest Cough Night time awakenings Chest tightness Shortness of breath with exercise Wheezing Difficulty getting air in/out Phlegm Other symptoms Year of diagnosis Is your activity, including exercise, restricted because of asthma? YES or NO What worsens your breathing symptoms (e.g. cold air, smoke)? What time of the year does your asthma worsen? How frequently do you have asthma exacerbations? How many nights a week/month? How often do you use your rescue inhaler? Have you ever been intubated? Number of ER visits Number of Hospitalizations? Number of missed work/school days How many times have you needed steroids (pills or injections) for asthma exacerbations? Have you had an x-ray or CT scan of your chest? YES NO If yes, when?
5 5 ECZEMA OR RASHES Do you have eczema? YES NO Location of rash How long have you had the rash: What medicines have you used for the rash? What soaps/lotions do you use? HIVES OR SWELLING Do you have hives or swelling? YES NO Location of the symptoms Please, describe your symptoms How long have you had hives or swelling? What worsens your symptoms? What medicines have you used for the symptoms? Do you have an EpiPen YES NO Have you had a biopsy? OTHER ALLERGIES Do you have a food allergy or suspected food allergy? YES or NO If yes, what foods and what type of symptoms? Have you eaten these foods since then? YES NO If yes, did you have a reaction? Have you ever had a serious or life -threatening reaction to an INSECT STING? YES or NO If yes, what was the reaction? Do you have an EpiPen? YES or NO X. Review of Systems Within the past month, (Please, check all that apply) Const. (Health in General) No Problems, Lack of energy, unexplained weight gain or weight loss, loss of appetite, fever, night sweats, pain in jaws when eating, scalp tenderness, prior diagnosis of cancer. Other: Ears, Nose, Mouth & Throat No Problems Difficulty with hearing, sinus problems, runny nose, post-nasal drip, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness. Other: C-V (Heart & Blood Vessels) No Problems Irregular heartbeat, racing heart, chest pains, swelling of feet or legs, pain in legs with walking. Other: Resp. (Lungs & Breathing) No Problems Shortness of breath, night sweats, prolonged cough, wheezing, sputum production, prior tuberculosis, pleurisy, oxygen at home, coughing up blood, abnormal chest x-ray. Other: GI (Stomach & Intestines) No Problems Heartburn, constipation, intolerance to certain foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained change in bowel habits, incontinence. Other: GU (Kidney & Bladder) No Problems Painful urination, frequent urination, urgency, prostate problems, bladder problems, impotence. Other: MS (Muscles, Bones, Joints) No Problems Joint pain, aching muscles, shoulder pain, swelling of joints, joint deformities, back pain. Other: Integ. (Skin, Hair & Breast) No Problems Persistent rash, itching, new skin lesion, change in existing skin lesion, hair loss or increase, breast changes. Other: Neurologic (Brain & Nerves) No Problems Frequent headaches, double vision, weakness, change in sensation, problems with walking or balance, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of visual loss. Other: Psychiatric (Mood & Thinking) No Problems Insomnia, irritability, depression, anxiety, recurrent bad thoughts, mood swings, hallucinations, compulsions. Other: Endocrinologic (Glands) No Problems Intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst, changes in sex drive. Other: Hematologic (Blood/Lymph) No Problems Easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia, unexplained swollen areas. Other: Allergic/Immunologic No Problems Seasonal allergies, hay fever symptoms, itching, frequent infections, exposure to HIV. Other:
6 6 II. PAST MEDICAL HISTORY: Please list your medical conditions: III. PAST SURGICAL HISTORY: Have you had any of the following surgeries in the past Sinus surgery Tonsillectomy/Adenoidectomy Ear Tube Placement Other surgeries: IV. FAMILY HISTORY: Has anyone in your family ever been diagnosed with any of the following conditions? (Circle all that apply) Hay Fever Food Allergy Asthma Eczema Hives Immunodeficiency Other illnesses: V. IMMUNIZATION HISTORY: Are your immunizations up to date? YES or NO Please list dates of vaccines: Influenza( flu ) Pneumococcal VI. MEDICATION HISTORY: Please, list the medications you are currently taking including prescription drugs, medications used occasionally, over-the-counter medications, vitamins, and herbal supplements below. VII. Drug Allergy: Yes No If yes, please list the name of medication and reaction VIII. SOCIAL HISTORY: Occupation Marital status Educational Level Do you have children?, If so, how many? Hobbies? Do You Smoke? Yes/No If YES, For How Long? How Much? Have You Quit Smoking? Yes No If YES, When? Do You Drink Alcohol? Yes No If YES, How Much? Do You Use Any Other Recreational Drugs? Yes No If YES, please list IX. ENVIRONMENTAL HISTORY Do you live in a house/apt/townhome, duplex, trailer? How old is your home? Do you have any pets? YES NO pets live: Indoors Outdoors Do pets sleep in bedroom? YES NO If yes, what kind and how many? Do the Is there anyone that smokes in your home? YES NO if YES, where do they smoke? INDOORS OUTDOORS Types of trees/greenery around your home? What type of pillows do you use(i.e. feather, down, etc.) Do you have carpet in your bedroom? YES NO If no, what type of flooring? Do you have any upholstered furniture in your bedroom? YES NO What type of window coverings do you have in your bedroom? How long have you lived in Virginia? Where did you live prior to moving to Virginia?
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
More informationRichmond Office 4718 National Rd. E. Richmond, IN
You have an appointment at Allergy & Asthma Care at the following address: Richmond Office 4718 National Rd. E. Richmond, IN 47374 765.966.0390 765.966.3343 You can visit our website at www.allergy-asthmacare.com
More informationRICHARD K. MARSCHNER JR., M.D., P.A. Ophthalmology
RICHARD K. MARSCHNER JR., M.D., P.A. Ophthalmology Palm-Aire Plaza 5889 Whitfield Avenue Sarasota, FL 34243 (941) 359-2900 Thank you for scheduling your eye exam with us. Please take a few moments to fill
More informationPLEASE DO NOT WEAR FRAGRANCES
Patient s Name: City: State: Zip: Male Female Race: Ethnicity: Language 1st: 2nd: Home Phone: Work Phone: Cell Phone: Email: Occupation: Employer: City: State: Zip: Family Doctor/Pediatrician: City: State:
More informationHospital 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
More informationALTERMAN & JOHNSON FAMILY CHIROPRACTORS and BLOOMING BELLIES. Application for Care
Application for Care Name Date: Address City State Zip Home Phone Work Phone Cell Phone Referred By E-mail Occupation Employer Date of Birth Age Marital Status S M D W Spouse s Name Spouse s Occupation
More informationPlease 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
More informationNew Patient Questionnaire
- - Toda y 's Date: Primary Care Provider's Name: Was a consultation recommended? Primary Clinic: Referring provider's name (if different): Please answer the following questions to facilitate the diagnosis
More informationCorinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
More informationVanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology
Kimberly L. Limbo, MD Kellie D. Anderson, CRNP Dear Parent, Thank you for choosing Huntsville Hospital Pediatric Neurology for your child s medical care. Our website should help answer any questions about
More informationDEVOE ALLERGY & ASTHMA CLINIC Phillip W. DeVoe, M.D., PA
WELCOME TO DEVOE ALLERGY AND ASTHMA CLINIC New Patient Instructions Thank you for choosing DeVoe Allergy and Asthma Clinic for your health care needs. We strive to make your visit as pleasant as possible.
More informationENT & Allergy Specialists of VA Registration Form
ENT & Allergy Specialists of VA Registration Form Which provider are you seeing today? Dr. James J. Lee Dr. Vickie K. Lee Dr. Rachel Watson Please Print Clearly Last Name PATIENT PERSONAL INFORMATION (please
More information9220 Haven Avenue, Suite 101 Rancho Cucamonga, CA Tel: (909) Fax: (909) ALLERGY HISTORY
Name: Date of Birth: Date of Visit: Briefly describe the reason for your visit: How long have you had these problems? How frequently do you have them? NASAL SYMPTOMS ALLERGY HISTORY 1. I have the following
More informationAmarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
More informationNEW 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
More informationNew Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
More informationPULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
More informationCASE 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.
More informationThe 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:
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 informationPREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit.
PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit. In order to obtain valid and useful skin testing results, you will need to stop the use of
More informationNew Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History
New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History Name PH#(home) Cell Address City Province Postal Code Date of Birth D/M/YY Age Gender Email address Do you exercise?
More informationNew Patient Information & Consents
New Patient Information & Consents Name: DOB: SSN: Gender: Address: City: State: Zip: Home #: Cell #: Other#: Employment Status: Occupation: Email Address: Marital Status: S M D W How did you hear about
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 informationSOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
More informationPULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
More informationSINAN DUZYUREK, MD, PLLC
PATIENT INTAKE FORM- CLINICAL INFO SECTION Your Name: Today s Date: Reasons for Seeking Professional Evaluation and/or Treatment During your session today Dr. Duzyurek will be conducting a diagnostic interview
More informationFamily Allergy Clinic
Please complete and bring these forms with you to your appointment. Patient Information: Family Allergy Clinic First Name: Last Name: Middle Initial: Preferred Name: Sex: Date of Birth: Social Security:
More informationRaleigh Psychiatric Associates, P. A Browning Place, Suite 201 Raleigh, NC Telephone Fax
James E. Bellard, M.D.,P.A. Thomas R. Spruill, M.D.,P.A. Philip L. Hillsman, M.D., F.A.P.A, Cherry Chevy, M.D. Rhonda H. Stahl, M.D. Zachary. W. Feldman, M.D. Alyssa Williams George, M.D. Dana C. Fennell,
More informationNew Life Allergy Treatment Center
New Life Allergy Treatment Center Your Natural Solution to Health New Patient Health History Name Ph#(home) (cell) Address City State Zip Code Date of Birth D/M/Y Age Gender Email Address Do you exercise?
More informationPatient Name: Date / Time of Appt: at
12422 South 450 East, Suite C, Draper, UT 84020 (801) 553-1900 Fax (801) 553-9995 Patient Name: Date / Time of Appt: at Duane J. Harris, MD and the staff of Intermountain Allergy & Asthma of Draper welcome
More informationAllergy & Asthma Consultants, L.L.P. 720 W. 34 th Street Suite 200 Austin, Texas Office (512) Fax (512) PATIENT INFORMATION
720 W. 34 th Street Suite 200 Austin, Texas 78705 Office (512) 454-5821 Fax (512) 459-9137 PATIENT INFORMATION MRN DR ENTERED VERIFIED Patient Information ( as it appears on insurance card) Last First
More informationWhich physician are you scheduled to see? Scheduled Appointment Date: As a reminder: Please arrive minutes prior to your scheduled appointment.
Which physician are you scheduled to see? Scheduled Appointment : As a reminder: Please arrive 15-20 minutes prior to your scheduled appointment. Please bring the following on the day of your scheduled
More informationALLERGIES: EMERGENCY CONTACTS Name Relationship to Patient Home/Cell Name Relationship to Patient Home/Cell
Instructions: Step 1 Call 719-687- 6088 Monday Friday from 12pm to 6pm to schedule your appointment Step 2 Print this PATIENT INTAKE FORM and fill it out Step 3 Scan and email it to us or fax it to us
More informationNEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
More informationName First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
More informationAllina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
More informationNEW PATIENT QUESTIONNAIRE
Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician
More informationAcupuncture & Herbal Therapies
Acupuncture & Herbal Therapies 2520 Central Ave. St. Petersburg, FL 33712 (Phone) 727-551-0857 (fax) 727-202-6896 Last Name: First Name: Male/Female: Date of Birth: Address: City: State: Zip: Home Phone#:
More informationAdult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
More informationTelephone Number Home: Work: Cell:
Page 1 of 7 Patient Name: DOB: Date: Address: Occupation: Telephone Number Home: Work: Cell: Emergency Contact: Relation: Telephone: Address: Referring Physician: Address: Telephone: ***ALL PATIENTS MUST
More informationPATIENT INFORMATION. Last Name First Name Address Zip Code City State
ADVANCED ALLERGY & ASTHMA, PLLC Ellen Epstein, M.D. FAAAAI, FACAAI Adult and Pediatric Allergy 165 North Village Avenue Suite 141 Diplomate American Board of Allergy and Immunology Rockville Centre New
More informationGUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
More informationRupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
More informationALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR
ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR Name D.O.B. Date Reason for your visit today: Please put a check and complete the blanks which apply to your symptoms: Present Problem Past Problem
More informationPATIENT 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
More informationConsent for Treatment Form
Consent for Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at Nourish: Healing
More informationOffice Policy for New Patients
Office Policy for New Patients Thank you for contacting us for your medical needs. We are glad you have entrusted us to be your medical provider. We are enclosing a few guidelines to help you transition
More informationWOODLANDS FAMILY CHIROPRACTIC
We appreciate you choosing our office. Is there anyone we can thank for referring you? Please indicate the main reason you are seeing us today: IF you are seeing us for a PAIN related issue, USE THE SYMBOLS
More informationMEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
More informationPlease be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
More informationTHE ALLERGY AND ASTHMA CLINIC
THE ALLERGY AND ASTHMA CLINIC ANDREW C. ENGLER, M.D. JUNE Y. ZHANG, M.D. BROOKE LEON, N.P. ELISABETH DENKER, N.P. Date: *Please plan on spending 2 hours at this first visit. Dear, We are looking forward
More informationNEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred
More informationWhere is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
More informationBridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
More informationReason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
More informationALLERGY AND ASTHMA CARE, P.A ELM CREEK BLVD. #200 MAPLE GROVE, MN TEL (763) FAX (763)
DATE: ALLERGY AND ASTHMA CARE, P.A. 12000 ELM CREEK BLVD. #200 MAPLE GROVE, MN 55369 TEL (763) 420-1010 FAX (763) 420-3710 LEGAL NAME: Last First Middle Initial ADDRESS: Street City State Zip Code DATE
More informationSymptom Review (page 1) Name Date
v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each
More informationNew Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
More informationSound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
More informationPatient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
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 informationGASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
More informationPATIENT 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
More informationNEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
More informationPatient 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
More informationPATIENT 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
More information(emergency room pain)
Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
More informationPatient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
More informationPatient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:
Dr. Bina Joseph Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician: Describe each problem that has led you to seek this allergy evaluation: 1. 2. 3. 4. Drug Allergies:
More informationKEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
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 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 informationPATIENT 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
More informationCaspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
More informationNEW PATIENT INFORMATION
NEW PATIENT INFORMATION Personal Mr. Ms. Mrs. Miss Dr. Other Last Name First Name MI Home Address City State Zip Mail Address City State Zip Is This a Nursing Home? Facility Name Telephone # Cell Phone
More informationAddress 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
More informationPatient 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:
More informationPatient Health History Questionnaire
Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com
More informationName: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
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 informationNEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
More informationDIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
More informationWELCOME 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
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 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 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 informationParkinson Disease and Movement Disorder Institute
428 East 72 nd Street (Between 1st Avenue & York Avenue), Suite 400 (Ground Floor), NY, NY 10021 Telephone: 212-746-2584 Fax: 646-962-0517 156 William Street, 11 th Floor (Between Ann Street and Beekman
More informationCHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
More informationOur staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite
More informationChiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
More informationPatient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
More informationPatient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
More informationPERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
More informationMedical 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
More informationCHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
More informationMudit Sharma, MD, FAANS, FACS Board Certified Neurosurgeon
PATIENT REGISTRATION & CONSENT PATIENT INFORMATION: Name: DOB: Age: Male: Female: Single: Married: Divorced: Widow: Address: Home #: Mobile #: SSN: Email Address: Race: Ethnicity: Language: EMPLOYMENT
More informationNew Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
More information