Welcome to Parkview Podiatry at Northern California Medical Associates
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- Hester McCarthy
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1 Welcome to Parkview Podiatry at Northern California Medical Associates The office of Alanna Wargula, DPM and Adelina Stateva, DPM 175 Park Street, Lakeport, CA Fax: Mendocino Ave Suite 300, Santa Rosa, CA Fax: Thank your for choosing our office for your foot and ankle care. We strive to provide you with efficient and courteous attention at each of your visits. We respect your time and make every effort to see you at your appointed time. It is our hope that the following information will answer any questions that you may have about our office, if you have any questions, please feel free to ask. Our Lakeport office is located at 175 Park Street in Lakeport, between 1 st and 2 nd Streets across from Library Park on beautiful Clear Lake and in Santa Rosa on Mendocino Avenue. Dr. Wargula (pronounced Wahrgooluh) is a local girl having grown up in Lakeport, graduating with honors from Clear Lake High. She attended Podiatry school in Miami, Florida and completed a 3 year residency program in Foot and Ankle surgery in Orange County, California after which she began her practice in 2008 with her friend and mentor Dr. James Hagan. She has been involved in many research studies and has published in orthopedic, podiatric, and wound journals. She is involved in multiple community projects including Habitat for Humanity, Russian River Cleanup, and Rebuilding Together. She resides in Santa Rosa with her husband and daughter, most of her family continues to reside here in Lake County. Dr. Stateva was born and raised in Bulgaria. She moved to the United States when she was 15 years old. Upon graduation from high school in Brooklyn, NY, she graduated with a Bachelor of Arts in Biochemistry at Connecticut College. She graduated from temple University School of Podiatric Medicine in 2002 and began residency at Palo Alto VA where she also taught at Stanford University and continued residency at Hahnemann University Hospital in Philadelphia. Returning to California in 2005 where she began her practice in Santa Rosa. She lives with her husband who is a professional chef in Santa Rosa and enjoys traveling and the outdoors. She and her husband also go on mission trips where they enjoy working with young children from all walks of life. Office Hours: We have 2 offices to serve you. Hours are by appointment. Appointments are available Monday thru Thursday in Lakeport (closed Wednesday) and in Santa Rosa on Friday. Dr. Hagan continues to see patients in the Lakeport office on most Fridays. Urgent appointments are available at both locations. We do not have an answering service. Voic is provided for your convenience, you may leave a message for a return call. If you have an after hours emergency, please call 911 or go to the nearest emergency room. Cancellations: If you are unable to keep an appointment, kindly notify our office at least 24 hours in advance. There is a $25 charge for no shows and short notice cancellations. Co-pays, Deductibles, and Billing: All co-pays and deductibles are due at the time of service. We also accept major credit cards. All billing is performed by Northern California Medical Associates. Office Procedures: Our office utilizes government certified electronic medical record software. Most of our charting is done in the exam room. We look forward to getting to know you and helping you improve and maintain your health
2 Welcome to Parkview Podiatry Alanna L. Wargula, DPM and Adelina Stateva, DPM Please have your insurance cards available and complete these forms in their entirety. Patient Information Patient Name: Gender: [] Male [] Female SS# / / Date of Birth: / / Address: Parent s Name: DOB: / / SS# / / Home Phone: Parent s Work Phone: Cell Phone: Primary Care Physician: Referred By: Insurance Information Primary Insurance: Insured s Name: ID# or SS#: Group#: Secondary Insurance: Insured s Name: ID# or SS#: Group#: Name of Responsible Party: Signature of Responsible Party: Date:
3 Patient Medical History Patient Name: Height: Weight: Medical Allergies: Medications (Please print names from your medicine bottles): Does the child have or has he/she ever been treated for any of the following?: [ ] Diabetes [ ] High Blood Pressure [ ] Liver Disease [ ] Heart Disease or Attack [ ] Stroke [ ] Cancer [ ] High Cholesterol [ ] Stomach Ulcer [ ] HIV/AIDS [ ] Hepatitis Type [ ] Reflux [ ] Asthma [ ] COPD [ ] Osteoporosis [ ] Kidney Disease [ ] Seizures [ ] Arthritis [ ] Rheumatoid Arthritis [ ] Thyroid (Hyper/Hypo) [ ] Parkinson s disease [ ] Psoriasis [ ] Multiple Sclerosis [ ] Fibromyalgia [ ] Gout [ ] Depression [ ] Anxiety [ ] Blood Clots [ ] Psychiatric Disorder [ ] Emphysema [ ] Circulation Problems [ ] Lupus [ ] Mitral Valve Prolapse [ ] Neuropathy [ ] Pacemaker [ ] Pain Syndrome [ ] Pneumonia [ ] Reynaud s [ ] Sickle Cell Anemia [ ] Skin Disorder [ ] Sleep Apnea [ ] Tuberculosis [ ] Other: Surgical History Please list any surgeries the child has had: Family History Does your family have a history of any of the following? [ ] Diabetes [ ] Cancer [ ] Coronary Artery Disease [ ] Heart Disease [ ] High Blood Pressure [ ] Stroke [ ] Thyroid Disease [ ] Rheumatoid Arthritis [ ] Blood Clots [ ] Other: Immunizations: Is your child up to date on immunizations? Yes No, which ones? Patient/Guardian Signature: Date:
4 History of Current Foot/Ankle Problem Name: Did the problem result from a specific injury? [ ] No [ ] Yes Please describe: Where is your pain/problem located? [ ] Toe [ ] Heel [ ] Ankle [ ] Ball of foot [ ] Arch [ ] Left [ ] Right [ ] Both [ ] Other: What is your complaint? How long have you had this complaint/condition? Please rate your pain on a scale of 1-10 (10 being the most painful): At rest: At its worst: Is the pain: [ ] Constant [ ] Occasional [ ] Sharp [ ] Dull [ ] Aching [ ] Stabbing [ ] Throbbing [ ] Radiating/Traveling Other: What symptoms are you experiencing? [ ] Locking [ ] Numbness [ ] Giving Away [ ] Popping [ ] Tingling [ ] Burning [ ] Grinding [ ] Swelling [ ] Bruising Other: Does anything make your symptoms feel better? Does anything make your symptoms feel worse? Have you seen another physician for this problem? What treatments have you tried? [ ] Nothing [ ] Physical therapy [ ] injections [ ] Bracing [ ] Icing [ ] Compression [ ] Medications [ ] Shoe change [ ] Arch support [ ] Massage [ ] Other Have you had any of the following tests/studies for this condition/complaint? Tests Date Facility X-rays MRI/CT Scan Nerve Study Blood Tests Other: Signature: Date: Thank you for completing these forms. We appreciate your efforts in filling them out completely. Please bring these forms with you to your appointment along with your insurance cards and with copies of any testing you have had performed. Please also sign the HIPAA form as this is a federal requirement to protect you for all disclosure of your health information.
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Welcome to Parkview Podiatry at Northern California Medical Associates
Welcome to Parkview Podiatry at Northern California Medical Associates The office of Alanna Wargula, DPM and Adelina Stateva, DPM 175 Park Street, Lakeport, CA 95453 707-263-9595 Fax: 263-5576 3536 Mendocino
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
Address 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
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
The failure to bring this information with you may result in the rescheduling of your appointment.
Alan Koester, MD Steven Novotny, MD John Jasko, MD Viorel Raducan, MD Brock Niceler, MD Thomas Reinsel, MD Chad Lavender, MD Thank you for choosing Marshall Orthopaedics! We will make every effort to ensure
\ NSMI. The National Sports Medicine InstJtute
~ \ NSMI The National Sports Medicine InstJtute 19455 Deerfield Avenue Su ite 3 12 Lansdowne, Virgin ia 20 I76 24430 Stone Spring Blvd, Suite 250, Dulles, Virginia 20166 Patient Information: Last Name:
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
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Address: City: State: Zip:
Practice: MARC B KLEIN DPM PA Appointment Date / / Patient Name: DOB: / / Chart Number: Office Use Only If patient is a minor, name of responsible parent: Sex: M F Marital Status: Single Married Widowed
New Patient Intake Form
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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
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone
Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?
Name: Sex: Male Female Date of Birth: Occupation: Is this a 2 nd opinion? Yes No Is this an accident or work related injury? Please list: Family MD: Referring MD: Address: Address: Phone: Phone: Fax: Fax:
Patient Information. Address: Street Apt. # City State Zip. Seasonal Address: (If different than above address) Address: Street Apt.
Page 1 of 6 Patient Information Name: Date of Birth: Age: Address: Seasonal Address: (If different than above address) Address: S.S. #: - - Sex: M F Marital Status: M S D Sep W Partnered Phone: Home (
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
Essex Podiatry Associates Jeffrey N. Kaplan, DPM Neil E. Goldberg, DPM
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MEDICAL HISTORY QUESTIONNAIRE
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Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:
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PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER
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PATIENT REGISTRATION
PATIENT REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single
Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right
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Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
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Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
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Helpful Telephone Numbers Pre-Registration 855-890-9241 Hospital Billing (NWH) 617-726-3884 Physician/Provider Billing (MGPO) 617-726-3884 Web Address nwh.org Pre-Registration Please call up to 7 days
Patient 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
Primary Care Physician: If Yes, where? Current work status: Full-Time Part-Time Self-Employed Unemployed Disability Retired
Name: Date of Birth: Primary Care Physician: Referring Physician: Have you had physical therapy during this calendar year? Yes No Have you had occupational therapy during this calendar year? Yes No If
Chiropractic Registration and History
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History of Present Problem
Patient Name: Date: If you are not the patient: Guardian name: Relationship to Patient: Height: Ft In Weight: lbs Age: Birth Date: Dominant Hand: Right Left Shoe Size: Primary Care Physician: Specialists:
Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right
Patient Information (Please Print)
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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
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History of Present Condition
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PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
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
GUPTA SPORTS & SPINE CENTER
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PATIENT DEMOGRAPHIC INFORMATION
PATIENT DEMOGRAPHIC INFORMATION Patient Name: (First, MI, Last) Sex: [ ] M [ ] F Birth Date: Age: SS#: Email: Race: Ethnicity: Language: Mailing Address: Work Ph: ( ) City: State: Zip Code: Home Ph: (
Please review the below items in preparation for your visit.
2001 Santa Monica Blvd., Suite #760W Santa Monica, CA 90404 (310) 582-7474 (Office) (310) 582-7481 (Fax) http://california.providence.org/saint-johns/services/orthopedics/ http://www.totaljoints.net/ Dear
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
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Past Skin History (Please check the applicable boxes to the patient s history or choose the first box)
Patient: First M.I. Last Date of Birth: Address: City: State: Zip Code: Responsible Billing Party: Social Security #: DOB: Home Work: Mobile: Best Contact number for confirmation calls is: Email (Required):
Primary Care Physician: Have you had physical therapy during this calendar year? Yes No
Name: Date of Birth: Primary Care Physician: Referring Physician: Have you had physical therapy during this calendar year? Yes No Have you had occupational therapy during this calendar year? Yes No If
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail 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
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Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
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)
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency