Chaffee County Public Health
|
|
|
- Heather Woods
- 5 years ago
- Views:
Transcription
1 Chaffee County Public Health 448 E. 1st Street Suite 137 Salida, CO Phone: Fax: Yellow Fever Vaccine Questionnaire Name: DOB: / / 1. Is this the first Yellow Fever Vaccine that you have received in your lifetime? a. if, when was your last: b. Other eplanation: 2. Have you experienced any side effects from previous Yellow Fever Vaccinations? a. if, please explain: 3. Do you or have you had your spleen removed, an organ transplant, leukemia, lymphoma, cancer, other malignancies &/or HIV/AIDS? 4. Have you been medically treated with chemotherapy or radiation therapy for cancer within the last three months? 5. Have you been on steriod theapy within the past month? 6. History of thymus disease, thymoma, Myasthenia Gravis and/or DiGeorge Syndrome? 7. Do you have a hypersensitivity/allegery to eggs, chicken, or gelatin? 8. Women Only: a. Are you pregnant or do you plan to become pregnant in the next month? b. Are you breastfeeding or do you plan to breastfeed in the next month? 9. Have you received a live vaccine within the past 4 weeks: (MMR, Varicella, Zostavax, and/or Flu Mist)? 10. Have you read the CDC's Vaccine Information Statement for the Yellow Fever Vaccine? A Yellow Fever Vaccine may be required on some visa applications, or to participate in some travel abroad programs. The Yellow Fever Vaccine is the ONLY vaccine required for entry by foreign governments at this time. This requirement is intended to keep their countries free of disease, T to keep you healthy. All other vaccines may be recommended, but will not be required for entry into a foreign country. Client Signature: Date: / /
2 **** FOR OFFICE USE ONLY**** TES: Nurse Signature: Date: / / Vaccine Recommendation: [ ] [ ] M.D. Consult: [ ] [ ] Recommendation from Medical Director: Medical Director Signature: Date: / /
3 Chaffee County Public Health 448 E. 1st Street Suite 137 Salida, CO Phone: Fax: Patient Information: Travel Pre-Immunization Questionnaire Last Name: First Name: Phone #: Date of Birth: / / Age: Gender: M F Weight (if child): Street Address: City/Town: State: Zip Code: Place of Birth (Country or state in US): Primary Language Spoken/Read: Occupation: Are you a person of Native American or Alaskan Native descent? Please List Medications: Name and Phone Number of preferred pharmacy: Health Questions: (if an answer is yes, please provide additional details on the space provided) 1. Are you sick today? 2. Do you have any allergies to food, medications, environment, latex? 3. Have you ever had a serious reaction to a vaccination? 4. Do you have any chronic conditions such as asthma, cardiac, respiratory, renal, musculockeletal, gastrointestinal, metabolic, or blood disorder, etc.? 5. Do you have, or had you had, cancer, leukemia, lymphoma, other malignancies, HIV/AIDS, complement, deficiency, your spleen removed, an organ transplant, immuyne system problem, thymus disease, Thymoma, Myasthenia Gravis, DiGeorge Syndrome, or any other long-term problems? 6. Have you had major surgery in the past 3 years? 7. Do you have a seizure disorder? 8. Do you live or work closely with anyone with an immune disorder?
4 9. Are you taking steroid, (cortisone/prednisone) or have you been on steroid therapy within the past month? Have you been treated with anticancer drugs (chemotherapy) or had radiation treatment within the last 3 months? Are you receiving antiviral drugs? 10. Are you taking aspirin or products containing aspirin? 11. In the past year, have you received a blood transfusion or had a gamma globulin injection? 12. Are you pregnant, trying to become pregnant, sexually active and not on birth control, or nursing a baby at this time? 13. Have you had any vaccines in the past 4 weeks? 14. Do you use tobacco products? 15. Do you currently have or had a history of: Antidepressant or psychiatric medication use: Depression, anxiety, panic attacks Psoriasis Heartburn, reflux, other intestinal issues History of Altitude Illness Achilles Tenson rupture or tendonitis Do you drink alcohol regularly Do you use recreational drugs Have you ever had Hepatitis Travel and Destination Information: Date of Departure from Home: Return Date/Length of Trip: Have you traveled internationally in the past? Where? Do you intend to travel frequently in the future? Maybe Itinerary: Please give ALL countries to be visited, including stopovers, in the order (if possible) to be visited: Destination: (check all that apply) Urban Rural Remote High Altitude Beach Is this a fixed itinerary? Not sure Purpose of Trip?: (check all that apply) Vacation Medical Care Business Education Adoption Volunteer/Humanitarian Visiting Friends and/or Relatives Long-Stay Traveler Organized Tour? Partly Explain:
5 Accommodations: (check all that apply) Hotel Hostel Rented House/Apt Camping Staying with Locals/Family/Friends Cruise Ship/Boat Will you be traveling alone? if no, explain: Planned Activities: (check all that apply) Air Travel Biking Hiking Snorkeling Swimming Rafting Boating SCUBA diving Climbing/Trekking Cave/Spelunking Public Transport: (bus, train, ect.) Other: Please Explain: Contact with Animals? Explain: Visting schools, hospitals, orphanages? Health Care Worker Occupational Exposure Other: Have you obtained travel medicine evacuation insurance? Do you consider yourself a risk-taker? Is there any other information about your trip, whether related to destinations or your activities while there, that you feel I should know in helping you determining safety and protection measures? Please Explain: Traveler's Stop Here For Nurse Only: Nurse Signature: Date: / /
6 IMMUNIZATION CONSENT FORM and HIPPA ACKWLEDGEMENT I authorize the vaccine information to be entered into the Colorado Immunization Information System (CIIS), under the Colorado Immunization Act. I authorize the release of information to or from: a health care provider, clinic, hospital, public health agency, school, and the CIIS. I understand the information will only be released for the specifici purpose of verifying immunization status. This authorization will remain valid for five years from the signature date. I can rescind (take back) this authorization at any time by requesting this of Chaffee County Public Health of this request, in writing. I realize staff may suggest certain vaccines that I am opposed to and I have a right to refuse them. I have read or have had explained to me the information in the Vaccine Information Sheets (VIS) for each vaccine I am receiving. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks associated withe the vaccines and have agreed to the vaccinations. I have given the most accurate and detailed information about my health in the questionnaire above (and for travelers, about my trip dates, and destinations) and give consent to the immunization services by Chaffee County Public Health. I have been advised that it is best to stay seated in the immunization or waiting room for 15 minuetes after receiving vaccines in case of allergic or adverse reaction. I authorize Chaffee County Public Health to share the necesarry information with my insurance company to try to receive payment, if it is thought that the vaccines are covered by my insurance, and am aware that payment from that insurance carrier may be sent directly to Chaffee County Public Health. I understand that I am finacially responsible for all charges wheter covered by insurance or not. I also understand that balances are required to be paid at the time of service. I acknowledge that I have been offered a copy of Chaffee County Public Health Health Notice of Privacy Practices. Date: / / Signature of Patient/Parent/Guardian Relationship to Minor Date: / / Signature of Chaffee County Public Health Staff
The following is a list of what you should bring to your travel appointment TenderCare International Travel Clinic
Thank you for contacting TenderCare Clinic s INTERNATIONAL TRAVEL CLINIC about immunization needs for your upcoming trip. At your travel clinic appointment, we will present you with a health risk assessment,
International Travel Medical Questionnaire
International Travel Medical Questionnaire Name: of Birth: Gender: M/F Last First Month/Day/Year Circle One Address: Street City, State Zip Daytime Phone: Evening Phone: Primary care physician: Emergency
International Travel Medical Questionnaire
Address Contact Phone # ITINERARY Date of Departure: Return Date: Please indicate, in the order you will visit them, the countries you are traveling to. Also indicate length of stay in each country. Destination
PRE- TRAVEL QUESTIONNAIRE
Ph: 03 313 7877 Fax: 03 313 7861 Email: admin@medicalcorner.co.nz 237 High Street, Rangiora 7400 PRE- TRAVEL QUESTIONNAIRE Please add as much detail to this form as possible as this will ensure that the
P L E A S E N O T E - There will be a charge for each person, even if your travel has been discussed previously with your own GP.
I M P O R T A N T - It is preferable that your Travel Consultation appointment is made one month prior to your departure. Please return this record this form promptly. You will be advised of an appointment
GracePointe Healthcare PLLC
GracePointe Healthcare PLLC Modern medicine the old fashioned way PLEASE PRNT AND COMPLETE N FULL Date Patient's Legal Name: Last First Nickname Sex: Male Female Birthdate: Age: Patient's Social Security
Infectious Diseases Consultants of Oklahoma City
Infectious Diseases Consultants of Oklahoma City Travel Clinic Questionnaire Patient Name:. DOB: / /. q first visit q return visit Adress: Phone: Primary Purpose of travel: q Business q Personal q Mission
Patient Questionnaire of the Creighton Travel Clinic Health Risk Assessment Instrument [01 revised Feb. 2012] Page 1 of 6.
![Patient Questionnaire of the Creighton Travel Clinic Health Risk Assessment Instrument [01 revised Feb. 2012] Page 1 of 6.](/thumbs/79/79019563.jpg "Patient Questionnaire of the Creighton Travel Clinic Health Risk Assessment Instrument [01 revised Feb. 2012] Page 1 of 6.")
Patient Questionnaire of the Creighton Travel Clinic Health Risk Assessment Instrument [01 revised Feb. 2012] Page 1 of 6 Would you, please...... fill in this form? Bring it with you when you come to the
Would you, please... fill in this form? Bring it with you when you come to the Travel Clinic. Thank you! Identification. Medical history.
Patient Questionnaire of the CHI Health Clinic Travel Clinic Health Risk Assessment Instrument [Nov 2017] Page 1 of 6 Would you, please...... fill in this form? Bring it with you when you come to the Travel
MEDICAL AND PERSONAL HISTORY
MEDICAL AND PERSONAL HISTORY Last First MI Today s Date Name Age Mr. Mrs Ms Dr Address Home Phone City, State, Zip Work Phone Sex: M F Patient SS# Cell Phone Date of Birth / / Responsible Party Referring
Module 7: Case Discussion and Administration Technique
: Case Discussion and Administration Technique Miranda Wilhelm, Pharm.D. Clinical Associate Professor Department of Pharmacy Practice Southern Illinois University Edwardsville, School of Pharmacy 1 Disclosure
Patient Enrollment Sheet
Patient Enrollment Sheet PATIENT INFORMATION: LAST NAME FIRST NAME MIDDLE INIT. STREET CITY STATE ZIP SSN DOB / / MALE / FEMALE HOME PHONE CELL PHONE WORK PHONE E-MAIL ADDRESS EMPLOYER YOUR OCCUPATION
The Middletown Township School District is hosting a Flu Clinic through Walgreens Pharmacy
The Middletown Township School District is hosting a Flu Clinic through Walgreens Pharmacy Walgreens Pharmacists will be at the following schools between 2:30 and 4:30 PM: Middletown High School North
Medical Forms and Information Peru
2013 Medical Forms and Information Peru The Medical Forms included in this document must be completed and returned to us no later than: June 5, 2013 1 Vaccinations & Medication The locations for STRIVE
Patient Immunization FAQ Sheet
Patient Immunization FAQ Sheet Shingles Vaccine: Q: Who should get the shingles vaccine (Zostavax )? A: Anyone 60 years of age or should get the shingles (herpes zoster) vaccine. There is no maximum age
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
MEDICAL AND PERSONAL HISTORY
MEDICAL AND PERSONAL HISTORY Last First MI Today s Date Name Age Mr. Mrs Ms Dr Address Home Phone City, State, Zip Work Phone Sex: M F Patient SS# Cell Phone Date of Birth / / Responsible Party Referring
1515 Strongs Avenue Administrative Services Stevens Point, WI
City of Stevens Point Department of 1515 Strongs Avenue Administrative Services Stevens Point, WI 54481-3594 715-346-1594 September, 2016 TO: FROM: RE: All Departments City Personnel Flu Vaccinations The
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM Dr. Mr. Mrs. Ms. Miss New Patient or Returning Patient FULL LEGAL NAME: Reason for today s visit: Mohs Excision Skin Check other:
FLU Clinic. Children 6 months through 18 years October 26 th, p.m. to 6 p.m. At the Milbank High School Lobby
FLU Clinic Children 6 months through 18 years October 26 th, 2016 2 p.m. to 6 p.m. At the Milbank High School Lobby MUST BRING: Insurance/Medicaid Cards All others please inquire. INFLUENZA 2016-2017 INACTIVATED
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY Tel # PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY 10016 Tel # 212-481-0064 PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A Last Name First Name Age Date Of Birth Sex Marital Status
Patient: First Name Middle Initial Last Name. Date of Birth SSN. Address . City State Zip Code. Home Phone ( ) Cell Phone ( )
PATIENT DEMOGRAPHICS PATIENT INFORMATION Patient: First Name Middle Initial Last Name Date of Birth SSN Gender: Male Female Address Email City State Zip Code Home Phone ( ) Cell Phone ( ) Occupation Employer
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
CHISHOLM 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
Initial Clinical History and Physical Form
601 E FM 544, Suite 400, Murphy, TX, 75094 TEL: 972-442-4700 Initial Clinical History and Physical Form Patient Information Name: Age: of Birth: / / Sex: Male / Female Marital Status: Single Married Divorced
New 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
Our 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.
Date: New Patient Form First Visit Date:
Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/
Access 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)
INFORMATION AND CONSENT FORM For Adults Aged 18 and Older Additional Facility Sites
INFORMATION AND CONSENT FORM Program Title: Expanded Access IND Program to Provide Stamaril Vaccine to Persons in the United States for Vaccination Against Yellow Fever Program #: Sponsor: Sanofi Pasteur
We are an academic institution What does that mean?
DERMATOLOGY & CUTANEOUS SURGERY We are an academic institution What does that mean? USF Health is an academic institution where future healthcare providers are trained. Below is a description of the different
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Home Phone #: Work Phone #: Cell
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Circle Preferred Phone Number Home
Kingsland Family Dental Registration and Medical History
Registration and Medical History Date: Patient Information Patient Name: DOB: / / Age Last First M Social Security# - - Sex: M F Marital Status: Single Married Child Other Spouse or Parent Name: Street
PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?
PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation
PATIENT DEMOGRAPHIC SHEET
PATIENT DEMOGRAPHIC SHEET Name: Date: Occupation: Gender: Marital Status: Date of Birth: SSN: HOME Street: City: State: Zip: Phone: Cell: Emergency contact : E-Mail Address WORK / SCHOOL Street: City:
STEPHEN C. SNITZER, D.D.S.,
STEPHEN C. SNITZER, D.D.S., M.S., P.C. PRACTICE LIMITED TO PERIODONTICS AND IMPLANTOLOGY DATE 14377 WOODLAKE DRIVE, SUITE214 CHESTERFIELD,MISSOURI 63017 (314) 434-2101 NAME How would you prefer to be addressed?
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
Frontier medical policy and malaria phrophylaxis advice
INFORMATION TO DISCUSS WITH YOUR DOCTOR Frontier medical policy and malaria phrophylaxis advice Please present this document to your doctor when you are discussing malaria phrophylaxis for your project.
MedDerm Associates, Inc.
*Last Name: PATIENT INFORMATION Please write CLEARLY and include any apt. # s, etc.., * Required information Today s Date: *First Name: *Primary phone: *Sex: M F Marital Status: S M W D DP *SS#: *Race
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY Patients s Name Date Yes No Yes No Anemia Arthritis Artificial Joints or Heart Valve Asthma Cancer/tumors Chest
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
Health Officer Order
September 24, 2018 Health Officer Order Mandatory Influenza Vaccination or Masking of Kern County Health Care Workers During Influenza Season UPDATE Dear Kern County Health Care Provider: In order to lower
NEW REQUIREMENT FOR THE SCHOOL YEAR:
Dear Parent/Guardian There are new immunization requirements for students that are entering the 7 th grade AND those entering the 12 th grade. NEW REQUIREMENT FOR THE 2016-2017 SCHOOL YEAR: Starting in
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,
General Recommendations on Immunization
General Recommendations on Immunization Epidemiology and Prevention of Vaccine- Preventable Diseases National Immunization Program enters for Disease ontrol and Prevention Revised January 2006 Issues Regarding
F M S M W D. Age Birth Date Gender Marital Status Cell Phone
MIDWEST DERMATOLOGY CLINIC, PC Patient Legal Name Last First Middle Initial Today s Date Mailing Address Street City and State Zip Home Telephone F M S M W D. Age Birth Date Gender Marital Status Cell
9/10/2018. General Best Practice Guidelines. General Recommendations. General Recommendations on Immunization
Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases General Best Practice Guidelines on Immunization Part Two Chapter 2 September 2018 Photographs and images
New 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?
Patricia C. McCormack, M.D., F.A.A.D.
Patricia C. McCormack, M.D., F.A.A.D. Diplomate of the American Board of Dermatology Adult & Pediatric Dermatology www.patriciamccormackmd.com PATIENT INFORMATION Today s date: Last name: First name: of
Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one. Primary Address: Street # Street name Apt# City State Zip
Elissa S. Norton, MD 5162 Linton Blvd, Suite 203 P: (561) 877-3376 F: (877) 992-1153 info@brilliantdermatology.com Name: Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one Primary Address: Street # Street
PATIENT REGISTRATION (Please Print)
14800 W. Mountain View Blvd., Suite 160 13090 N. 94 th Drive, Suite 101 Surprise, AZ 85374 Peoria, AZ 85381 (623) 584-3376 (623) 584-3376 Fax: (623) 584-3375 Fax: (623) 584-3375 PATIENT REGISTRATION (Please
Patient Intake Sheet
Patient Intake Sheet Patient Information Name: Cell Phone: ( ) Address: Work Phone: ( ) Emergency Phone: ( ) Email Address: Date of Birth: Age: Who referred you? Weight: Height: Who is your primary care
Retinal Consultants of San Antonio PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Referred by Patient Full Name Home Address City State Zip Code Home Phone Cell Phone E-mail address Date of Birth Preferred Method of Contact: Home Phone / Cell Phone
Welcome to Dr Jamie Italiane-DeCubellis s office
Welcome to Dr Jamie Italiane-DeCubellis s office Thank you for choosing our healthcare team for your dental needs. Our goal is to make your experience here pleasant and to provide you with high-quality
Address (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
Patient Information. Account #: Date: Person Responsible For Payment (Other than patient):
Patient Information Account #: Date: Race: Ethnicity: Tobacco Use: White or Hispanic Asian Black or African American Native Hawaiian or Pacific Islander American Indian or Alaskan Native Hispanic or Latino
PLEASE 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#( ) [
Highland Colony Dental- Donald K. Givan, DMD
Highland Colony Dental- Donald K. Givan, DMD ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRAcTICES *You May Refuse to Sign This Acknowledgement* I, have received a copy of this office s Notice of Privacy
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
Norovirus in Healthcare Settings
ST. JAMES HEALTHCARE DECEMBER 2012 INFECTION PREVENTION NEWSLETTER INSIDE THIS ISSUE: Norovirus in Healthcare Settings The Impacts of Unsafe Medical Injections in the U.S. Preparing Your Skin Before Surgery:
Office 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
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
Patient Intake Sheet
Patient Intake Sheet Patient Information Name: Cell Phone: ( ) Address: Work Phone: ( ) Emergency Phone: ( ) Email Address: Date of Birth: Age: Who referred you? Weight: Height: Who is your primary care
Our Mission. To promote healthy and safe travel by providing medicines, preventive vaccines and health counseling to a diverse group of travelers
Our Mission To promote healthy and safe travel by providing medicines, preventive vaccines and health counseling to a diverse group of travelers The Travel Clinic utilizes national and international travel
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:
Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse
PATIENT INFORMATION NAME: LAST FIRST MIDDLE ADDRESS: CITY: STATE: ZIP CODE DOB: / / AGE: MARITAL STATUS: M S D W SEP
PATIENT INFORMATION DATE: SS#: NAME: LAST FIRST MIDDLE ADDRESS: CITY: STATE: ZIP CODE DOB: / / AGE: MARITAL STATUS: M S D W SEP Primary contact #: ( ) Is this: Home Cell Work Other: May we leave a detailed
Medicare Patient Enrollment Sheet
Medicare Patient Enrollment Sheet PATIENT INFORMATION: LAST NAME FIRST NAME MIDDLE INIT. STREET CITY STATE ZIP SSN DOB / / MALE / FEMALE HOME PHONE CELL PHONE WORK PHONE E-MAIL ADDRESS EMPLOYER YOUR OCCUPATION
Volunteer Applicant Health Clearance Checklist
Volunteer Applicant Health Clearance Checklist Employee Health Contact Information Office Phone: (202) 715-4275; Fax: (202) 715-4587; Email: gwuehs@medcor.com Walk-in hours: M-F 8:00 a.m. 12:00 p.m. &
DENTAL QUESTIONNAIRE
Name: (First) (Last) (Preferred) Birthdate: (Month) (Day) (Year) Gender: Male Female Address: City: Prov: Postal Code: Cell Phone: (Number will be used for confirmation of appointments) Email Address:
Zika: Frequently Asked Questions
4824-16 NJ Zika Facts Flier 0216 Version 021616 ENGLISH STATE COPY Stock ID: Reading Level: 5.9 excluding company name, proper nouns, phone numbers, website urls, sources and terms microcephaly, insect
Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE
PATIENT INFORMATION PATIENT INTAKE FORM BANGOR PODIATRY, LLC Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE ADDRESS: STREET
PATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:
Title:! Mr.! Mrs.! Ms.! Miss! Dr. PATIENT REGISTRATION INFORMATION Patient: Last Name: First Name: Middle: Wish to be called: D.O.B.: / / Age: Sex:!Male! Female SSN: - - Marital Status:! Single!Married!
CHESTERFIELD VALLEY DERMATOLOGY
Chesterfield Valley Dermatology Helen Kim-James, MD 100 Chesterfield Business Parkway, Suite 110 Chesterfield, Mo 63005 P: 636.532.0990 f: 636.532.0993 CHESTERFIELD VALLE DERMATOLOG PATIET IFORMATIO FORM
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
6140 W Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)
Cosmetic Patient Information Today s Date: Reason for visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip Secondary (Out of State) Address: Street City/State/Zip
WELCOME 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:
Comfort Foot Care HIPPA COMPLIANCE FORM. Home Phone Cell phone Mail SMS
Please answer the following questions. Comfort Foot Care HIPPA COMPLIANCE FORM 1. What is your contact preference? Circle all that apply Home Phone Cell phone Mail Email SMS 2. May we leave lab, testing
Patient 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:
HEALTH 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
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC 28470 Patient Demographic Information Account # Last Name: SSN: / / First: Middle: Marital Status: Single Married Separated Nickname:
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship
Robert Antonelle, M.D. White Plains Gastroenterology 311 North Street, Suite 403 White Plains, NY 10605 Patient Demographics Patient s Last Name First Name Middle Initial SSN Date of Birth Age Gender F
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
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
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
HEALTH OFFICE, Poughkeepsie, NY Residential Student:
Residential Student: The Health Office welcomes you to residential living. It is our goal in collaboration with Residential Life, Safety, and Security, and the Dean of Students to promote health and wellness
Kids Dental Care Adult Patient Registration
Kids Dental Care Adult Patient Registration To be updated every two years Patient's Name: DOB: SS# Sex: Male / Female Address: Apt/Unit/Floor: City: State: Zip Code: Home Phone #: ( ) - Cell Phone #: (
Dear Parent/Guardian:
Dear Parent/Guardian: Margaret Mary Health (MMH) has agreed to give the flu (influenza) vaccine to the students at your child s school on October. 30th MMH highly recommends the FluMist vaccine which is
We look forward to seeing you. Please feel free to call us with any questions.
1227 E. 9th Street Edmond, OK 73034 Phone: (405) 475-0100 Fax: (405) 475-9275 https://susandimickmd.com Welcome to Dr. Dimick s Office. We appreciate the opportunity to provide your health care needs.
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive Florence, Alabama
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive 256-766-0270 Father: DOB: SS#: Home Address: Home #: Work #: Cell #: Employed By: Address: Do you have dental insurance? Yes No
NEW PATIENT HEALTH HISTORY
Meeks and Zilberfarb Orthopedics 1101 Beacon Street. Brookline, MA 02246 40 Allied Drive, Dedham, MA 02026 Tel: 617-232-2663 Fax: 617-232-6342 Tel:781-326-1561 Fax:781-326-1562 Jeffrey L. Zilberfarb, MD
Student Health and Immunization Record
Student Health and Immunization Record Instructions for students: Health screening and immunization requirements for the Physician Assistant Program are based on current Centers for Disease Control recommendations
Patient Registration
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
HISTORY AND INTAKE FORM
PATIENT NAME: HISTORY AND INTAKE FORM DOB: DATE: Asthma Atrial fibrillation Bone marrow transplantation Breast cancer Colon cancer COPD Coronary artery disease (heart disease) Diabetes End stage renal
Hillsboro Middle School/Hillsboro High School 550 US 62 South Hillsboro, Ohio /
Hillsboro Middle School/Hillsboro High School 550 US 62 South Hillsboro, Ohio 45133 937-393-9877/ 937-393-3485 Jason Snively, HS Principal Kathy Hoop, MS Principal Laura Johnson, District School Nurse
GEORGE WASHINGTON UNIVERSITY HOSPITAL EMPLOYEE HEALTH SERVICES REQUIREMENTS FOR CLEARANCE:
GEORGE WASHINGTON UNIVERSITY HOSPITAL EMPLOYEE HEALTH SERVICES Office: 202 715 4275 Fax: 202 715 4587 Email: gwuehs@medcor.com Walk-in hours: M-F 8am-12pm and 1pm-4pm REQUIREMENTS FOR CLEARANCE: Physical