ABOUT HEARING HEALTH CENTER
|
|
|
- Elijah Summers
- 6 years ago
- Views:
Transcription
1 ABOUT HEARING HEALTH CENTER Hearing Health Center has been providing hearing health care and treatment to our community for over 30 years. We are known for our skill and expertise in identifying hearing and balance problems, offering a wide variety of treatment options, helping you chose the right solution, and outstanding service. We have won awards from multiple organizations and the State of Illinois for always going above and beyond. Our Doctors of Audiology specialize in individual and customized treatment. Every doctor has completed over 1800 hours of supervised training to provide you with unparalleled care. Hearing and balance involve the brain. Your brain must be able to receive clear and detailed signals from these systems for you to hear clearly, understand speech and to maintain your balance at all times. Brain retraining, relearning, and rehabilitation are critical for successful outcomes. Hearing Health Center works with every manufacturer to offer a wide variety of treatment options and find the right solution for you. We collaborate with many specialists in the medical community to ensure that you receive the best possible care. Financing and payment plans are available for cost concerns. The Fisher Foundation for Hearing Health Care provides treatment and care for those who qualify.
2 College Rd. Wehrli Road Naper Blvd. MAP OF HEARING HEALTH CENTER: 1212 S Naper Blvd # 103, Naperville IL Covenant Church Chase Dunkin Donuts Market Ave. Starbucks House of Ace Emporer Hardware GNC US Burger King Massage Envy ATI McDonald s PNC Hearing Health Center Hallmark Naperville Christian Church Sign: Market Meadows Sign: Fox Run Square 75 th Street Mariano s Directions via I-88 From the east: 1. Head west on I-88 W and exit toward Naperville Rd. 2. Turn right onto Freedom Dr. 3. Turn right onto E Warrenville Rd. 4. Turn right at the 1st cross street onto N Naper Blvd./Naperville Rd. Continue south on Naper Blvd. for about 4 miles. From the west: 1. Head east on I-88 E and exit on Naperville Rd. 2. Use the right 2 lanes to turn right onto Freedom Dr (signs for Naperville Rd S/Diehl Rd) 3. Turn left onto Diehl Rd. 4. Turn right onto N Naper Blvd/Naperville Rd. Continue south on Naper Blvd. for about 4 miles.
3 Patient Information First Name: Middle Initial: Last Name: Address: Unit #: City: State: Zip: Sex: M F Birthdate: Employment Status: Retired Full Time Part Time Student Occupation/Former Occupation: Marital Status: Single Married Divorced Widowed Partner How did you hear about us? Contact Information Home Phone: Work: Mobile: Preferred method of contact: Home Work Cell Text Emergency Contact: Relation: Phone: Insurance Information Primary Insurance: Secondary Insurance Name of Insured: Relation to Patient: DOB: Primary Care Physician: Phone #: Address: City: State/Zip: Health History List all medications, condition being treated and length of time taking: Reason for appointment: Have you had a hearing test in the last 10 years?: Y N Do you currently use hearing aids? Y N When purchased: Place of purchase:
4 Consent Form Financial Agreement I hereby give authorization for payment of insurance benefits to be made directly to the provider and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection and reasonable attorney s fees. I hereby authorize Hearing Health Center to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original. Insurance authorization must be obtained before a patient is seen. If I do not inform the Providers seen in this clinic of my current insurance and the insurance is denied because of no authorization, I will be responsible for payment. If prior authorization or referral is not obtained from the insurance company before my scheduled appointment and I still choose to see the Provider, I will be responsible for the bill at the time of service. Patient Name (Print) Signature of responsible party Today s Date Notice of Privacy Practices I hereby acknowledge that I received a copy of Hearing Health Center s Notice of Privacy Practices. I give Hearing Health Center permission to release information, verbal and written, to my insurance company, case manager, attorney, related healthcare providers, beneficiaries and all other related persons. Information without patient identifiers may be used for quality purposes. I acknowledge I have been given the opportunity to review the Health Insurance Portability & Accountability Act (HIPAA) policy in this office. Signature Date If not signed by the patient, please indicate the relationship between the signee and the patient: Parent or guardian of minor patient Guardian or conservator of a patient HIPPA Consent to Leave Voic /Message I do I do not give permission to leave relevant medical information on my answering machine or voic . I do I do not want relevant medical information shared with the person who may answer the telephone. The names of the individual(s) with whom you may leave pertinent information are: Signature Date
5 Why Hearing is Your Most Important Sense We learn to talk by imitating the sounds we hear. Throughout childhood, we learn by hearing and listening to our teachers, our parents, and our friends. We develop friendships and relationships by hearing and responding to those we like. Much of the joy in our life is from communicating with our family, our friends, and members of the groups we join. Communication makes us feel secure and gives us a sense of belonging. The ability to communicate via the spoken word is what separates man from all other animals. Effective communication depends on our capacity to hear the spoken word. Our entire life changes when communicating becomes difficult, stressful, and frustrating. We feel isolated and depressed. We withdraw, lose interest, and stop participating in the groups and activities that once gave us pleasure. We become angry, paranoid, and fearful. Our hearing is our only long-distance sense, and the only one that works 24 hours every day. Our hearing keeps us in touch with our surroundings (rain on the roof, sirens approaching, footsteps behind us, the TV in another room) and is on even when our eyes are closed and sleeping, letting us know when the baby is crying or the smoke alarm is beeping. We depend on our hearing more than any other sense, yet we rarely think about it and consider it low on our priority list of health concerns. You Hear With Your Ears, You Listen With Your Brain Our ears collect sounds and send them to the communication area of our brain to filter, process, interpret, and make sense of the sounds it received. Even a small decrease in hearing reduces the amount of stimulation and information our brain needs to decipher messages. As our hearing ability worsens, our brain can no longer separate important speech sounds from other extraneous noises. Our brain must work harder trying to make sense of only partial information. If the deprivation continues, our brain will give up. Unless it starts getting back the stimulation it lost, the processing area of our brain begins to deteriorate. Our cognitive function is irreversibly and permanently impaired. Hearing Impacts Your Memory and Your Balance When decreased hearing ability prevents our brain s processing area from receiving necessary information, our brain must work harder. Resources are taken from other areas of our brain to try to communicate. Scientists call it cognitive overload because this rewiring stresses and strains our brain. The extra load on our brain prevents the transfer and storage of information to our short-term memory. We cannot remember what we did not hear or misheard, and we can no longer even remember what we did hear. Our hearing ability keeps us grounded and oriented in our space. Reduced awareness of our environment increases our likelihood of falling three times.
Home Sleep Test (HST) Instructions
Home Sleep Test (HST) Instructions 1. Your physician has ordered an unattended home sleep test (HST) to diagnose or rule out sleep apnea. This test cannot diagnose any other sleep disorders. 2. This device
Family 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
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 Birth / / Sex: Male Female
Name Preferred Name. Date of Birth / / Gender: Male Female Other. SSN - - Preferred Phone Other Phone. Street Address. City State Zip Code
New Patient Information Name Preferred Name last first mi Date of Birth / / Gender: Male Female Other SSN - - Preferred Phone Other Phone Email Address Street Address City State Zip Code Employment Full
Patient Name Date of Birth / / Today s Date / /
Dr. Mark Valente Dr. Andy Indresano Board Certified, Fellowship Trained Phone. 972.707.0005 Fax. 888.992.6199 DISCspine.com New Patient Intake Form Name First MI Last Street Address Apt # _ City _ State
New Patient Information
Patient's Street Address: Home Phone: Cell Phone: of Birth: / / New Patient Information State: Name of Person Responsible for This Account: E-Mail Address: Zip Code: Work Phone: SSN: Do You Have Dental
Audiology Adult Intake Questionnaire
Audiology Adult Intake Questionnaire IDENTIFYING INFORMATION Patient full name: Preferred Name: Date of birth: Gender: Male Female Social Security: Address: City: State: Zip: County: What is the patient
Child s Legal Name: Nickname: Male Female. Birth Date: Age: School: Grade: FATHER STEPMOTHER GUARDIAN? Insured s Name: D.O.B. Social Security #:
Welcome Welcome to our practice! We strive to make each of your child s visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep their smile beautiful for their
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:
CONDITIONS OF SERVICES RENDERED
CONDITIONS OF SERVICES RENDERED FINANCIAL AGREEMENT: I agree, whether I sign as agent or as patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate
Please list medications and dosage (including non-prescriptions) you are currently taking or have taken recently:
Name: DOB: Today s Date: Primary Care Doctor: Referring Physician: What is the primary reason for today s visit? Medical History Please list medications and dosage (including non-prescriptions) you are
Natural Health Center
Natural Health Center 420 Yucca Lane - Turpin, OK 73950 Tel. No. (580) 778-3310 / Cell No. (620) 391-5520 / Fax No. (580) 778-3340 Today s Date / / Application for Treatment Name: Birthdate: SS# Address:
Journey to Truth Counseling
ADULT / COUPLE INTAKE FORM (Please Print) Date: / / Social Security # Date of birth: Age: Mr. Ms. Dr. Mrs. Miss. Rev. Full Name (Last) (First) (Middle) Parent/Guardian/Power of Attorney: (if applicable)
PATIENT INTAKE FORM Health & Wellness
PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
Tennessee State University Department of Speech Pathology & Audiology
Tennessee State University Department of Speech Pathology & Audiology Intensive Articulation, Fluency, Language & Diagnostics Summer Speech Camp 2014 Speech Pathology and Audiology will provide intensive
Upperman Family Dental NEW PATIENT REGISTRATION
Date Upperman Family Dental NEW PATIENT REGISTRATION First Name Middle Initial Last Name Patient is: Policy Holder Responsible Party Preferred Name Address Address 2 City, State, Zip Home Phone Cell Phone
PATIENT INFORMATION. Soc. Sec. #: First Initial Last. Name Relationship Phone Number. Employer. Occupation
Patient s Name Residence Address Mailing/Temporary Address Home Phone Best day time contact? Home Cell Work Email PATIENT INFORMATION Soc. Sec. #: First Initial Last. and Street City State Zip Code. and
State: Zip Code: Home Phone#: Child resides with: Both Parents Mother Father Other Parent s address:
Child s Name: Address: Today s Date: City: State: Zip Code: Home Phone#: Date of Birth: Age: Gender/Sex: Male Female Child resides with: Both Parents Mother Father Other Parent s email address: Mother
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
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
Carter Physiotherapy, PLLC Patient Contact Information
Carter Physiotherapy, PLLC Patient Contact Information Patient Name Today s Date Address City State Zip DOB Age Gender Marital Status Cell Phone Home Phone Email Employer Occupation Parent/Guardian/Spouse
Allergy & 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
NEW PATIENT PACKET Welcome To Our Clinic!
NEW PATIENT PACKET Welcome To Our Clinic! Name: Date: Address: City: State: Zip Code: Shipping address: Home phone: ( ) - Cell phone: ( ) - E-mail: Date of Birth: Age: Gender: F / M / MTF / FTM Height:
Cy-Fair Hearing Aids Case History Form. Brandy R Jacobson Au.D. PERSONAL INFORMATION. Patient Name: Appointment Date: Date of Birth: Age: Gender: Male
Cy-Fair Hearing Aids Case History Form Brandy R Jacobson Au.D. PERSONAL INFORMATION Patient Name: Appointment Date: Date of Birth: Age: Gender: Male Female Marital Status: Single Married Divorced Widowed
PATIENT ENTRANCE FORM
PATIENT ENTRANCE FORM Name _ Date Address City/ Province Postal Code Home Telephone Work Telephone Email Address Would like email reminders for appointments? Yes No Date of Birth (Day/Month/Year) Age Marital
New Patient Information
New Patient Information Bloomfield Children s Dentistry 6405 Telegraph Road Bloomfield Hills, MI 48301 In order to get to know your family better, and to provide you with the best service, we ask that
PATIENT S NAME GENDER First Middle Init. Last Male/Female. Home Address. PATIENT EMPLOYER Bus. Phone. Employer Address. NAME OF SPOUSE Birth Date
PATIENT INFORMATION RECORD The following information is needed for our records. Please print answers to all questions. PATIENT S NAME GENDER First Middle Init. Last Male/Female Birth Age Marital Status
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
Welcome to our Office
HSPI revised 102014 Welcome to our Office Lorin S. Oden, AuD, FAAA Doctor of Audiology Hearing Solutions of North Carolina, PLLC Ph.: 704-633-0023 Fax: 704-705-2363 464 Jake Alexander Blvd., West Salisbury,
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.
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
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
JACKSONVILLE SPEECH & HEARING CENTER PATIENT INFORMATION FORM PEDIATRIC (CHILD) - AUDIOLOGY Please Print
JACKSONVILLE SPEECH & HEARING CENTER PATIENT INFORMATION FORM PEDIATRIC (CHILD) - AUDIOLOGY Please Print Referring Physician: Child s (Patient) Name: LAST FIRST MIDDLE Gender: Male Female Date of Birth:
Name 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
FRANCIS AUDIOLOGY ASSOCIATES (PLEASE PRINT)
FRANCIS AUDIOLOGY ASSOCIATES (PLEASE PRINT) DATE LAST MI FIRST STREET ADDRESS CITY STATE ZIP Home Phone: Work: Cellphone: Birthdate: Age Marital Status Sex: M F Employed: Full Time Part-time Retired Student
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
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
Family Dental Care of Gainesville, PLLC Dr. Matthew Bayne, DDS 112 N. Denton Street Gainesville, TX Offce phone:
Family Dental Care of Gainesville, PLLC Dr. Matthew Bayne, DDS 112 N. Denton Street Gainesville, TX 76240 Offce phone: 940-665-4211 FINANCIAL AGREEMENT Welcome to Family Dental Care of Gainesville! Thank
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:
PSYCHOLOGIST-PATIENT SERVICES
PSYCHOLOGIST-PATIENT SERVICES PSYCHOLOGICAL SERVICES Welcome to my practice. Because you will be putting a good deal of time and energy into therapy, you should choose a psychologist carefully. I strongly
WHAT IF MY CASEWORKER WON'T CALL ME BACK?
WHAT IF MY CASEWORKER WON'T CALL ME BACK? Sometimes it is difficult for people who get benefits from DHS to reach their caseworker. There are many times when it is very important to reach a caseworker;
Welcome to Saratoga Ophthalmology!
Amjad M. Hammad, MD, MBA Salman J. Yousuf, DO The Center for Vitreo-Retinal Surgery Charles H. Rheeman, MD Gregory B. Krohel, MD The Center for Oculoplastics & Neuro-Ophthalmology Kamran I. Chaudhri, MD
Windrose Naturopathic Clinic Family Practice Preventative Care 1137 W Garland Ave, Spokane WA (509) (509) (fax)
NEW PEDIATRIC PATIENT INFORMATION Date: To be filled out by parent or guardian: Child s Name: Age: DoB: Height: Weight: Address: City, State, Zip Male Female Parent / Guardian Information: Name: Phone:
FONTBONNE UNIVERSITY Department of Communication Disorders and Deaf Education
FONTBONNE UNIVERSITY Department of Communication Disorders and Deaf Education Eardley Family Clinic for Speech, Language and Hearing 6800 Wydown Boulevard, St. Louis, MO 63105-3098 (314) 889-1407 (314)
GARDEN STATE SLEEP CENTER REGISTRATION FORM PATIENT INFORMATION:
GARDEN STATE SLEEP CENTER REGISTRATION FORM (Please Print) Today s Date: Primary Care Physician: PATIENT INFORMATION: Last Name: First: Middle: Mr. Miss Dr. Mrs. Ms. Marital Status (Please check one) Single
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)
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
th Street Urbandale, IA YOST
YfC 3993 100th Street Urbandale, IA 50322 515.278.YOST www.yostfamilychiropractic.com Demographics: Language (Primary) Race: Unspecified American Indian or Alaska Native Black or African American Other
Amanda G. Johnson, LPC
Adult Personal Information Name Date Address Apt City State Zip Code E-mail Is it OK to contact you at this email address? YES NO Home Phone Is it OK to leave a message for you at this number? YES NO Cell
Sleep Medicine Associates
Date: Patient Name: DOB: Patient Height: _ Weight: _ lbs Referring Physician: Neck Size: Main Sleep Problems: 1. My main sleep complaint is: Trouble Sleeping at night Sleepy during the day Unusual behavior
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
Tennessee State University Department of Speech Pathology & Audiology Intensive Language, Articulation, Fluency, & Diagnostics Summer L.A.F.
Tennessee State University Department of Speech Pathology & Audiology Intensive Language, Articulation, Fluency, & Diagnostics Summer L.A.F. Camp 2017 The Department of Speech Pathology and Audiology will
Family 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:
Liberty Chiropractic Clinic Scarsdale Blvd., Houston, TX
Liberty Chiropractic Clinic, -6154 Patient's Name Patient's Address City State Zip Code Age D.O.B. Single Married Divorced Widowed No. of children Occupation Employer Home Phone Work Phone Cell Phone Email
PATIENT REGISTRATION FORM
Please Print PATIENT REGISTRATION FORM Date: Who can we thank for referring you to our office? Patient Name (First) (Middle) (Last) Preferred Name (if applicable) DOB Sex: Male Female Patients Address
WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas (972) Personal Information
WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas 75019 (972) 393-3937 (Please Print Clearly) Personal Information Last Name: First Name: Exam Date: / / Street Address: City/State/Zip:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (Please print clearly) Last Name MI First Name Date of Birth Home Address Mailing Address if different Home Phone Work Phone Other/Cell Phone EHR Certification Patient Information
Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
Patient Registration (Please fill out one per family)
Patient Registration (Please fill out one per family) Child s First and Last Name: Date of Birth: Child s Preferred Name: Gender: Male Female Child s Address: Child s City, Zip Code: Additional Children
Lake Psychological Services, LLC
Lake Psychological Services, LLC Welcome to Lake Psychological Services and thanks for choosing our office for your health care needs. Seeking treatment is not an easy decision and you may have questions
HEAR NOW Program. Application 2014
HEAR NOW Program Application Valid through December 15, Page 1 Dear Applicant, Thank you for contacting the HEAR NOW Program of Starkey Hearing Foundation for hearing aid assistance. Our hope is to provide
WELCOME PATIENT INFORMATION. Name Patient Prefers to be called Address. Home Address City State Zip Code How Long. Birth Date / / Month Day Year
14 North Hale Grantsville UT 84029 WELCOME Today s date: Thank you for entrusting your oral health care to our team of dental professionals. We are committed to serve you with the best in dental care while
BRIGHT AUDIOLOGY NOTICE OF PATIENT INFORMATION PRACTICES
BRIGHT AUDIOLOGY NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW YOUR MEDICAL RECORDS MAY BE USED OR DISCLOSED AND HOW YOU CAN ACCESS YOUR MEDICAL RECORDS. PLEASE REVIEW IT CAREFULLY.
Chiropractic for pediatric development and adult health
Raleigh Specific Chiropractic Chiropractic for pediatric development and adult health 7721 Six Forks Rd. Suite 138 Raleigh, NC 27615 (919) 846-7004 Items to bring to your first visit: All new patient paperwork
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
WEBSTER CHIROPRACTIC CARE
WEBSTER CHIROPRACTIC CARE Name: Address: City: Zip Code: Marital Status: M S Phone: Cell: Age of Birth Email: May we contact you or send helpful health information via Email? Yes or No Would you like E-mail
Family-to-Family 2019 Teacher Training Application & Agreement
Family-to-Family 2019 Teacher Training Application & Agreement TRAINING LOCATION: Yakima 2-DAY TRAINING SCHEDULE APPLICATION DEADLINE Saturday, June 29, 2019 8:00 am 7:30 pm Friday, June 7, 2019 Sunday,
Lions Sight & Hearing Foundation Phone: Fax: Hearing Aid: Request for assistance
Lions Sight & Hearing Foundation Phone: 602-954-1723 Fax: 602-954-1768 Hearing Aid: Request for assistance 3427 N 32 nd Street office use only Date received Case number Applicant: (Name; please print clearly)
Tell Us About Your Child. Who is Accompanying Your Child Today? Parent Information. Primary Dental Insurance
1 Today s Date: 2 (225) 664-2646 (225) 664-2640 (fax) 245 VETERANS BLVD. DENHAM SPRINGS, LA 70726 Who is Accompanying Your Child Today? Name: Relation: Do you have legal custody of this child? Yes No Tell
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
Tell Us About Your Child
5C Medical Park Drive Pomona, NY 10970 (845) 414-9626 drsmith@smithslittlesmiles.com www.smithslittlesmiles.com Marita Smith, DDS Board Certified Pediatric Dentistry We are thrilled to welcome you and
SOUTHSIDE COMMUNITY ACUPUNCTURE, LLC. Financial Policies
Disclosure of Information - Please Read the Following Carefully How to Prepare for Your First Visit : Plan on showing up a 15 minutes early to your first appointment and please wear, or bring with you
Junior Volunteer Application
Junior Volunteer Application The mission of GROW is to cultivate, conserve, engage and explore. Thank you for your interest in helping us. To be considered as a possible JR Volunteer, please complete the
New Patient Information Packet
New Patient Information Packet Thank you for scheduling your appointment with our North Scottsdale office. We look forward to meeting you! We find it can be helpful to bring a friend or family member whose
OUTPATIENT SERVICES PSYCHOLOGICAL SERVICES CONTRACT
OUTPATIENT SERVICES PSYCHOLOGICAL SERVICES CONTRACT (This is a detailed document. Please feel free to read at your leisure and discuss with Dr. Gard in subsequent sessions. It is a document to review over
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
Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
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#( ) [
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
Welcome to Lone Lake Physical Therapy!
Welcome to Lone Lake Physical Therapy! **Please arrive 5-10 min prior to your appointment time for your first session. Your appointment will last approximately 55-60 min What you should know before your
Patient Information Form
Patient Information Form Patient Name: (Last) (First) (MI) Name you prefer to be called: Mailing address: City: State: Zip: Best daytime phone: May we leave a message there? Yes No Alternate phone number:
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
634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
Chiropractic Health Dr. Art Vanderhoef
Patient Information Form Chiropractic Health Dr. Art Vanderhoef File # Name Address City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Email Address How do you prefer to be contacted? Mail Home
Client Intake Form Therapeutic Massage
Personal Information: Client Intake Form Therapeutic Massage Name Phone (Day) Phone (Eve) Address City/State/Zip email Date of Birth Occupation Emergency Contact Phone The following information will be
PRIMARY INSURANCE. Subscriber Name: Subscriber ID/Policy #: Relationship to Patient: Self Wife Husband Parent Other Assignment of Insurance Benefits
PATIENT INFORMATION FORM MRN: Appt Appt Time: Last Name: Social Security #: First Name: Mid. Initial: Date of Birth: Home Address: Age: Sex: Home Address 2: Home Phone #: City, State, Zip: Work Phone #:
Due Process Hearing Request Information Sheet and Model Form
Oregon Department of Education Office of Learning/Student Services 255 Capitol Street NE Dispute Resolution Section Salem, OR 97310-0203 (503) 947-5689 Due Process Hearing Request Information Sheet and
These materials are Copyright NCHAM (National Center for Hearing Assessment and Management). All rights reserved. They may be reproduced
These materials are Copyright 2015-2017 NCHAM (National Center for Hearing Assessment and Management). All rights reserved. They may be reproduced and distributed in print or electronic format at no cost
Please call at least 24 hours in advance to cancel any appointment. You may be charged a $20.00 fee for a no call/ no show office visit.
Welcome to the Sleep Disorders Center at Kettering Medical Center. We would like to ask that you fill out the following information before you arrive to the sleep clinic on your scheduled appointment.
Welcome to Skyline Pediatric Dentistry!
Welcome to Skyline Pediatric Dentistry! Patient Information Patient Name: Preferred Name: Today s Date: Birth Date: Age: Social Security #: Male Female Names of siblings: Responsible Party Information
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:
Which 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
2010 Sharing Hope Program for men
2010 Sharing Hope Program for men Criteria and Application Made possible by participating sperm banks and fertility centers Program Overview Goal Cancer patients have little opportunity to save for the
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY Welcome! PLEASE PRINT CLEARLY PERSONAL DATA Today s Date First name MI: Last name: Nickname Gender M F Age Date of Birth SS# (optional) Current address
MEDICAL HISTORY FORM
MEDICAL HISTORY FORM Patient Name: Date of Birth: Date: Email: Address: Emergency Contact (name, relationship to patient, & phone): Height: Weight: Right/Left Hand Dominant: [ ] Male [ ] Female What area
SonoMarin Neurofeedback Eileen Roberts PhD
SonoMarin Neurofeedback Eileen Roberts PhD 707.338.9084 drrobs@hotmail.com Patient Information Name: Social Security #: Address: Home Telephone: City: Zip: Cell Phone: Date of Birth: Marital Status: Spouse/Parent
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Insurance Information Release Form
Insurance Information Release Form Policy Holder s Information Policy Holder s Name Birthday Social Security Number Spouses Name Birthday Social Security Number Dependent's Name (last name if different
PATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN