Generic Pre Operative Physical Form

Size: px
Start display at page:

Download "Generic Pre Operative Physical Form"

Transcription

1 Generic Pre Operative Free PDF ebook Download: Generic Pre Operative Download or Read Online ebook generic pre operative physical form in PDF at From The Best User Guide Database Yes. No. APPLICATION FORM FOR MPUMALANGA IDC/UL NGUNI CATTLE DEVELOPMENT. PROJECT 2013/2014. CO-OPERATIVE DETAILS. Co-operative Inpatient Physical Therapy Management of the patient with a spinal disorder undergoing operative primary form of medical treatment. Specifically, this. discussion with the MD or PA regarding the appropriateness of PT evaluation or. Optimizing intraoperative and peri-operative care, and the monitoring and treatment of other. Post-operative Patient Management.. V. Post-operative Device Management.. nurses, dieticians, exercise physiologists, and potentially,. POLICY: 1. All post operative patients will have a physical assessment completed and documented per: Assessment: Scope of Nursing Physical Assessment:. PDF Document Bellow will provide you all related to generic pre operative physical form! Generic Camp med form 05 Sportime Generic Camp Med 05 Sportime The Suffolk County Dept. of Health requires that we have the information Kindly forward this form to your child's physician and have him/her complete and. This PDF book include generic health form for camp information. To download free generic camp med form 05 sportime you need to

2 GENERIC SPEECH INTRODUCTION GENERIC SPEECH INTRODUCTION GENERIC SPEECH INTRODUCTION.. RETURN TO TOASTMASTER BEFORE THE MEETING BEGINS!. Give Your Manual to your Evaluator before the This PDF book include generic speeches conduct. To download free generic speech introduction form you need to GENERIC TRANSCRIPT REQUEST FORM GENERIC TRANSCRIPT REQUEST FORM permission to. (student's name). (school providing transcript) send copies of my official transcript to the name and address identified below. (number). This PDF book incorporate request school transcript form template conduct. To download free generic transcript request form you need to A Generic Processing Approach for Large Variant A Generic Processing Approach For Large Variant A Generic Processing Approach for Large Variant Templates. Yaakov Navon, Ella registration is done with no modification to the input form image, since. This PDF book include generic registration form template information. To download free a generic form processing approach for large variant you need to Generic Authorization to Release Medical Records form Generic Authorization To Release Medical Records I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. PATIENT This PDF book incorporate generic release of medical record form information. To download free generic authorization to release medical records form you need to Generic authorization medical release form AdhEYa Generic Authorization Medical Release AdhEYa HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT All medical records, meaning every page in my record, including but not limited to:. This PDF book incorporate generic release of medical record form document. To download free generic authorization medical release form adheya you need to Generic letter of introduction and consent form Concordia Generic Letter Of Introduction And Consent Concordia Letter of Introduction and Informed Consent This statement describes the purpose and procedures of the study.. withdraw from the study at any time. This PDF book include sample letter for withdrawal study conduct. To download free generic letter of introduction and consent form concordia you need to purchase requisition generic on line form Clinton County Purchase Requisition Generic On Line Clinton County PURCHASE REQUISITION. COUNTY OF CLINTON. Phone: Fax: DATE: PO #: ACCOUNT #: Vendor Code: VENDOR: BILL TO/SHIP TO: Customer #. QUANTITY. This PDF book include generic purchase requisition form information. To download free purchase requisition generic on line form clinton county you need to

3 Generic Sponsorship Agreement 2011 WIPO JIPO Generic Sponsorship Agreement 2011 WIPO JIPO regarding ABC's sponsorship of the 2012 SPORT EVENT. 1.. For example, you may need to acknowledge and agree that any. ABC Competitor may purchase. This PDF book provide sports sponsorship agreement template guide. To download free generic form sponsorship agreement 2011 wipo jipo you need to generic order form Richard Montgomery Athletic Boosters Generic Order Richard Montgomery Athletic Boosters Richard Montgomery Team Photo Order Packages and Pricing. Package 1. (1) 5x7 team photo. (2) 4x6 individual player photos. ($23 value). This PDF book include sports team photo order form template document. To download free generic order form richard montgomery athletic boosters you need to Guide to Fill out Generic Insurance Dr. Sima Aidun Guide To Fill Out Generic Insurance Dr. Sima Aidun Box 15, 16, 17, 18, 19, 20, can leave blank. 12. Box 21: important: in front of each number write down your ICD-9 code ( will be on your superbill). 13. BOX 22,23: This PDF book contain blank superbill information. To download free guide to fill out generic insurance form dr. sima aidun you need to generic race entry form Oklahoma Sports & Fitness Generic Race Entry Oklahoma Sports & Fitness Page 1. This PDF book contain ok sports and fitness magazine conduct. To download free generic race entry form oklahoma sports & fitness you need to P reparticipation Physical Evaluation. HISTORY FORM. (Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician This PDF book provide history and physical form information. To download free physical form you need to ihsaa Ihsaa (1 of 4). Preparticipation Physical Evaluation. HISTORY FORM. (Note: This form is to be filled out by the patient and parent prior to seeing the physician. This PDF book contain history and physical forms information. To download free physical form ihsaa you need to CooperRiis CooperRiis from Applicant's MEDICAL Treatment Team. Applicant's Name General Medical History: A. Please. C. Is this applicant capable of participating in a life skills program which includes physical work outside? If not, explain. This PDF book include general work physical form document. To download free physical form cooperriis you need to

4 Sports Sports Physical Page 1. Sports. Name: Gender: M F. Date of Birth: / /. Father's Name: Daytime phone, pager, cell phone: Mother's Name: Daytime This PDF book incorporate sports physical form sample guide. To download free sports physical form you need to History and Physical form History And Arcadia Home Health/Home Care Services. HISTORY AND PHYSICAL FORM. (To be completed by Physician). I. PERSONAL INFORMATION. Date of Exam. This PDF book incorporate history and physical form guide. To download free history and physical form you need to Physical Examination Physical Examination 2010 National Commission for the Certification of Crane Operators. All rights reserved. MCO CH REV 11/10. Physical Examination. Please type or print This PDF book provide crane operator physical examination form conduct. To download free physical examination form you need to VHSL VHSL Physical VHSL Athletic Participation/Parental Consent/. In order for In order for the physician to be able to do the physical examination, this form must be. This PDF book include vhsl physical form document. To download free vhsl physical form you need to Pre-participation Physical form Pre-participation Preparticipation Physical Evaluation. HISTORY FORM. (Note: This form is to be filled out by the patient and parent prior to seeing the physician.) Date of Exam This PDF book include history and physical exam template document. To download free pre-participation physical form you need to Physical Exam Physical Exam P reparticipation Physical Evaluation. HISTORY FORM. (Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician This PDF book provide sample of physical examination form information. To download free physical exam form you need to Physical examination NCCCO Physical Examination NCCCO MEDICAL EXAMINER'S CERTIFICATE. I certify that I have examined. CRANE OpERATOR'S NAME with the knowledge of his/her duties,. I find him/her qualified This PDF book incorporate crane operator physical examination form guide. To download free physical examination form nccco you need to

5 Physical Therapy Fax Referral Physical Therapy Fax Referral Fax to We will call patient to schedule their appointment. also available at. Date / /. This PDF book incorporate sample physical therapy referral form conduct. To download free physical therapy fax referral form you need to History & Physical (H&P) Mi Via, NM Self-Directed History & Physical (H&P) Mi Via, NM Self-Directed History & Physical (H&P). Mi Via, NM Self-Directed Medicaid Waiver Program. (If your office or practice has its own H&P form, it may be used in place of this This PDF book include history and physical form guide. To download free history & physical (h&p) form mi via, nm self-directed you need to PHYSICAL THERAPY REFERRAL FORM PHYSICAL THERAPY REFERRAL FORM PHYSICAL THERAPY REFERRAL. Traditional & Pilates-Based Rehabilitation. Patient's Name: Doctor's Name: NPI#: Diagnosis: DOI: Procedure(s) Performed:. This PDF book include sample physical therapy referral form conduct. To download free physical therapy referral form you need to Annual Physical Visit Annual Physical Visit C:\Users\MattKerlin\Desktop\PA1051A Annual Physical Visit form 1-18-cx. 1. PARTNERSHIP ADVANTAGE/ANNUAL VISIT. HISTORY AND PHYSICAL This PDF book include yearly physical forms information. To download free annual physical visit form you need to Preparticipation Physical Evaluation Preparticipation Physical Evaluation Aug 14, This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) evaluation which may include a physical examination. This PDF book provide blank history and physical template guide. To download free preparticipation physical evaluation form you need to EMPLOYEE PHYSICAL EXAM FORM EMPLOYEE PHYSICAL EXAM FORM EMPLOYEE PHYSICAL EXAM FORM. Please return completed form to the Personnel Office. 53 Gibson Road, Goshen, New York Employee's Name:. This PDF book incorporate physical exam form for employment document. To download free employee physical exam form you need to Physical Exam and Immunization Physical Exam And Immunization form completed by a licensed medical practitioner. All health care workers providing services under this contract must meet all the requirements specified under. This PDF book incorporate health care worker physical exam form conduct. To download free physical exam and immunization form you need to

6 PHYSICAL EXAMINATION FORM NJCAA PHYSICAL EXAMINATION FORM NJCAA Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram). 10. Do you get lightheaded or feel more short of breath than This PDF book incorporate pediatrician physical exam form template document. To download free physical examination form njcaa you need to Pre-Employment History and Pre-Employment History And Pre-Employment History and. Personal Data. Name (Last, First, MI): SSN: Date of Birth: / /. Age: Ethnicity: Phone Numbers: Home ( ) -. Mobile ( ) -. This PDF book contain pre employment physical form samples guide. To download free pre-employment history and physical form you need to 2014 Pop Warner 2014 Physical Pop Warner Mar 3, PHYSICAL FITNESS & MEDICAL HISTORY FORM No other forms are acceptable unless Section II is modified or substituted ONLY to. This PDF book contain history and physical forms conduct. To download free 2014 physical form pop warner you need to SportsMedicine of Atlanta SportsMedicine Of Atlanta Has a doctor ever ordered a test for your heart? (for example: ECG, echocardiogram). 11. Has anyone in your family died for no apparent reason? 12. This PDF book provide generic physical exam form document. To download free physical form sportsmedicine of atlanta you need to NEW EMPLOYEE PHYSICAL EXAM FORM Choices NEW EMPLOYEE PHYSICAL EXAM FORM Choices Traditional Coverage. NEW EMPLOYEE PHYSICAL EXAM FORM. (Please Print). Today's date: Patient Insurance ID Number: PATIENT INFORMATION. Patient's This PDF book contain physical exam form for employment conduct. To download free new employee physical exam form choices you need to SIU Family Medicine: History and SIU Family Medicine: History And Male: penile discharge, sores, testicular pain / mass, and. Physical Exam: Bullet and subsequent content *Qualifying systems. *Constitutional:. This PDF book provide penile exam form template conduct. To download free siu family medicine: history and physical form you need to Pre Participation University Interscholastic Pre Participation University Interscholastic This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and medical evaluation which may include a physical examination. This PDF book incorporate history and physical forms information. To download free pre participation physical form university interscholastic you need to

7 General Medical/Physical Exam General Medical/Physical Exam GENERAL MEDICAL/PHYSICAL EXAM FORM. PATIENT'S NAME. Page 1 of 2. SOCIAL SECURITY. NUMBER (Last 4 digits only). DATE. AGE. PATIENT'S This PDF book incorporate generic physical exam form information. To download free general medical/physical exam form you need to Pre-employment Hutchinson Clinic Pre-employment Hutchinson Clinic Pre-Employment / Job Placement Medical Questionnaire. Name I hereby declare the answers I have given above are accurate to the best of my knowledge: X. This PDF book include pre employment physical form samples document. To download free pre-employment physical form hutchinson clinic you need to PHYSICAL THERAPY INITIAL EVALUATION FORM PHYSICAL THERAPY INITIAL EVALUATION FORM PHYSICAL THERAPY INITIAL EVALUATION FORM. PATIENT INFORMATION 4. HAVE YOU RECEIVED THERAPY FOR THIS CONDITION? YES NO WHEN? This PDF book provide physical therapy initial evaluation template document. To download free physical therapy initial evaluation form you need to form a: confirmation of knowledge of physical therapy and A: Confirmation Of Knowledge Of Physical Therapy And May 12, THERAPY AND LETTER OF RECOMMENDATION #1. I. INSTRUCTION TO THE APPLICANT: Please complete this section before giving the This PDF book provide pt letter of recommendation document. To download free form a: confirmation of knowledge of physical therapy and you need to Norwood City Schools Norwood City Schools Do you have seasonal allergies that require medical. 2. Do you have any current skin problems (for example,. Preparticipation Physical Examination. This PDF book provide physical examination form example conduct. To download free physical form norwood city schools you need to Homestead Physical Education Make-Up Homestead Physical Education Make-Up P. E. Teacher This form must be completed and returned to the student's PE teacher. 1.. the sport, questions to be answered, and crossword and word search. This PDF book provide physical education word search answers document. To download free homestead physical education make-up form you need to mybooklibrary.com

Pediatrics History And Physical Template

Pediatrics History And Physical Template Template Free PDF ebook Download: Template Download or Read Online ebook pediatrics history and physical template in PDF Format From The Best User Guide Database History & Outline Discharge Summary Template.

More information

History And Physical Template For Hospitalist

History And Physical Template For Hospitalist Template For Hospitalist Free PDF ebook Download: Template For Hospitalist Download or Read Online ebook history and physical template for hospitalist in PDF Format From The Best User Guide Database Consultation

More information

NEW PATIENT PAPERWORK

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

More information

July, Dear Parents and Coaches:

July, Dear Parents and Coaches: July, 2007 Dear Parents and Coaches: Cary S. Keller, MD, FACSM and Sportsmedicine Fairbanks are pleased to provide the Fairbanks Community with Sportsmedicine and Orthopaedic quality care. The mission

More information

PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER

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#( ) [

More information

SAMPLE. Dental Claim Form. X Patient/Guardian Signature. X Subscriber Signature. X Signed (Treating Dentist) 54. NPI 55.

SAMPLE. Dental Claim Form. X Patient/Guardian Signature. X Subscriber Signature. X Signed (Treating Dentist) 54. NPI 55. HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Dental Claim Form fold fold Statement of Actual Services EPSDT / Title XIX 2. Predetermination/Preauthorization Number RECORD OF SERVICES

More information

Massage Therapy Incident Report Form

Massage Therapy Incident Report Form Incident Report Form Free PDF ebook Download: Form Download or Read Online ebook massage therapy incident report form in PDF Format From The Best User Guide Database If the status of the claim is pending,

More information

Chiropractic Case History/Patient Information

Chiropractic Case History/Patient Information Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:

More information

Superbill For Massage Therapy

Superbill For Massage Therapy Superbill For Massage Free PDF ebook Download: Superbill For Download or Read Online ebook superbill for massage therapy in PDF Format From The Best User Guide Database ejacobsmassage@. The Center (Saturday

More information

Training Application for

Training Application for STRENGTH Rx REAL TRAINING NO GIMMICKS HARD WORK REAL RESULTS Training Application for STRENGTH Rx Welcome to STRENGTH Rx. We offer Strength & Conditioning training for all athletes looking to improve all

More information

PROGRAM YEAR 2018 REGISTRATION PACKAGE

PROGRAM YEAR 2018 REGISTRATION PACKAGE PROGRAM YEAR 2018 REGISTRATION PACKAGE Full Stride Track Club is a competitive track club for Contra Costa and Solano County youth ages 5 to 18 years old. We are committed to providing our youth with a

More information

Casamba Physical Therapy Documentation Examples

Casamba Physical Therapy Documentation Examples Casamba Examples Free PDF ebook Download: Casamba Examples Download or Read Online ebook casamba physical therapy documentation examples in PDF Format From The Best User Guide Database Page 1 Guidelines

More information

MOUNT VERNON CITY SCHOOL DISTRICT ATHLETICS and HEALTH SERVICES

MOUNT VERNON CITY SCHOOL DISTRICT ATHLETICS and HEALTH SERVICES STUDENT NAME SPORT DATE GRADE LEVEL COACH PARENT/GUARDIAN ATHLETIC PARTICIPATION CONSENT FORM *PLEASE RETURN THIS FORM ON THE DAY THE ATHLETE HAS HIS/HER PHYSICAL/CONFERENCE* Dear Parent or Guardian: Your

More information

Sunshyne Smiles Program Orthodon c Assistance Applica on (to be completed by parent/guardian)

Sunshyne Smiles Program Orthodon c Assistance Applica on (to be completed by parent/guardian) Orthodon c Assistance Applica on (to be completed by parent/guardian) Child s (First) (MI) (Last) Birthdate: Sex: Male Female Parent/Guardian Name (s): Address: City/State/Zip: (First) (MI) (Last) Daytime

More information

4. ADD/ADHD Medical Documentation Athlete is responsible for reading, completing, and providing required documentation.

4. ADD/ADHD Medical Documentation Athlete is responsible for reading, completing, and providing required documentation. LAST NAME FIRST SPORT Returning Student-Athlete Health Information ONLY complete this booklet if you play varsity men s or women s soccer, women s volleyball, men s golf, men s or women s swimming, men

More information

Chiropractic Case History/Patient Information

Chiropractic Case History/Patient Information 1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:

More information

COAHOMA COUNTY SCHOOL DISTRICT Application for Interim Superintendent of Schools

COAHOMA COUNTY SCHOOL DISTRICT Application for Interim Superintendent of Schools COAHOMA COUNTY SCHOOL DISTRICT Application for Interim Superintendent of Schools (Please type or print your responses and fully respond to each item.) I. BASIC INFORMATION Name: (Last) (First) (Middle)

More information

APPLICATION FELLOWSHIP IN IMPLANT DENTISTRY PROGRAM

APPLICATION FELLOWSHIP IN IMPLANT DENTISTRY PROGRAM : Application Date Month Day Year University of Rochester University of Rochester Medical Center Eastman Institute for Oral Health 625 Elmwood Avenue Rochester, New York 14620-2989 USA (585) 275-8315 Paste

More information

Junior Volunteer Application

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

More information

New Patient Information

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

More information

FULL DAY Application Checklist

FULL DAY Application Checklist Batesville Primary School 760 State Road 46 West Batesville, IN 47006 812-934-4509 www.batesvilleinschools.com/bps Student s Name Last First Middle 2016-2017 FULL DAY Application Checklist The following

More information

Grant Application for Individuals

Grant Application for Individuals Grant Application for Individuals Thank you for your interest in applying for a grant from Small Steps in Speech, a nonprofit 501(c)3 foundation created in memory of Staff Sgt. Marc J. Small. The Board

More information

Address (if different from above):

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

More information

FRESHMEN/TRANSFER STUDENT CHECKLIST

FRESHMEN/TRANSFER STUDENT CHECKLIST FRESHMEN/TRANSFER STUDENT CHECKLIST Pre Participation Questionnaire Medical Consent Form Insurance Form Please include a copy of the FRONT and BACK of your insurance card. Pre Participation Physical Form

More information

APPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY)

APPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY) 1317 w. Washington Blvd. Fort Wayne, In. 46802 260-424-2341 APPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY) NAME: _ FIRST MI LAST DATE OF BIRTH: / / AGE: SOCIAL SECURITY NUMBER: LAST OR CURRENT ADDRESS:

More information

NEW YORK STATE MEDICAID PROGRAM HEARING AID PRIOR APPROVAL GUIDELINES

NEW YORK STATE MEDICAID PROGRAM HEARING AID PRIOR APPROVAL GUIDELINES NEW YORK STATE MEDICAID PROGRAM HEARING AID PRIOR APPROVAL GUIDELINES Version 2015 1 (10/1/2015) Page 1 of 12 TABLE OF CONTENTS Section I - Purpose Statement... 3 Section II - Instructions for Obtaining

More information

Dear Prospective UMD Teen PEERS Parents:

Dear Prospective UMD Teen PEERS Parents: Dear Prospective UMD Teen PEERS Parents: Thank you for your request to be a part of our University of Maryland Teen PEERS program at the Department of Hearing and Speech Clinic. Before we can schedule

More information

ADA 2012 Dental Claim Form

ADA 2012 Dental Claim Form Claim Form Effective April 1, 2014, the West Virginia Medicaid and WVCHIP Program s claims processing system will begin accommodating the national version of the Claim Form. For Dental claim filing purposes,

More information

Sample Casamba Therapy Documentation

Sample Casamba Therapy Documentation Sample Casamba Free PDF ebook Download: Sample Casamba Download or Read Online ebook sample casamba therapy documentation in PDF Format From The Best User Guide Database Progress Notes serve as documentation

More information

Tell Us About Your Child

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

More information

2. To provide trained coaches/ volunteers and specialized equipment at accessible facilities for sports clinics.

2. To provide trained coaches/ volunteers and specialized equipment at accessible facilities for sports clinics. Medstar NRH Adapted Sports Policy 1. Programs are open to anyone in the Washington Metropolitan area with a physical disability. Interested participants are pre-screened by coaches to determine eligibility

More information

New Patient Information

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

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Rehabilitative Therapy Services

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Rehabilitative Therapy Services Fee-for-Service Provider Manual Rehabilitative Therapy Services Updated 12.2015 PART II (PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH/LANGUAGE PATHOLOGY) Introduction Section BILLING INSTRUCTIONS Page

More information

St. Mary s Hospital Foundation Scholarship Program. Deadline: Must be postmarked by March 15, 2016

St. Mary s Hospital Foundation Scholarship Program. Deadline: Must be postmarked by March 15, 2016 St. Mary s Hospital Foundation Scholarship Program Deadline: Must be postmarked by March 15, 2016 MedStar St. Mary s Hospital Human Resources Department 25500 Point Lookout Road Leonardtown, MD 20650 For

More information

Tomorrow s SMILES Program

Tomorrow s SMILES Program Do you know a promising teen whose future is at-risk due to lack of dental treatment? Would your teen and his or her family understand, appreciate, and value pro-bono dental care? If so, your teen may

More information

Celebration Lutheran School

Celebration Lutheran School Celebration Lutheran School Wisconsin Interscholastic Athletic Association Athletic History and Physical Examination Approval for TWO YEARS of Competition All students participating in interscholastic

More information

Reject Code Reason for Rejection What to do

Reject Code Reason for Rejection What to do Reject Code Reason for Rejection What to do 10 Hospital where services rendered missing or invalid. Input the Hospital where services were rendered on the HCFA. 11 Patient first name missing or invalid.

More information

Washington County-Johnson City Health Department Christen Minnick, MPH, Director 219 Princeton Road Johnson City, Tennessee Phone:

Washington County-Johnson City Health Department Christen Minnick, MPH, Director 219 Princeton Road Johnson City, Tennessee Phone: Washington County-Johnson City Health Department Christen Minnick, MPH, Director 219 Princeton Road Johnson City, Tennessee 37601 Phone: 423-975-2200 Dear Parent: The Washington County Health Department

More information

Multi-Diagnostic Services, Inc.

Multi-Diagnostic Services, Inc. Multi-Diagnostic Services, Inc. 139-16 91st Avenue Jamaica, New York 11435 718 454-8556 Fax: 718 454-7950 Name: Date of Appointment: AM Time: PM What to Expect and How to Prepare for the Mammography Screening

More information

Calumet 2017 staff/trainee/volunteer Health History & Examination Form PO Box 236, West Ossipee, NH Fax

Calumet 2017 staff/trainee/volunteer Health History & Examination Form PO Box 236, West Ossipee, NH Fax Calumet 2017 staff/trainee/volunteer Health History & Examination Form PO Box 236, West Ossipee, NH 03890 The information on this form is to assist us in determining appropriate care for staff/trainees/volunteers.

More information

WV Address WV Phone # Father / Male Guardian Information (required) Work Phone # Home Phone # Cell Phone # Home Address (if different)

WV Address WV Phone # Father / Male Guardian Information  (required) Work Phone # Home Phone # Cell Phone # Home Address (if different) 2016 Freestyle/Freeski BagJump/Trampoline Skills Training Sessions & 6 Day Camp Application For each athlete, please complete, sign and return all pages of this application and include payment in full

More information

Policy / Drug and Alcohol-Free Workshops

Policy / Drug and Alcohol-Free Workshops Policy 4118.235/4218.235 Drug and Alcohol-Free Workshops DATE: February 13, 2017 PREVIOUS ITEM: None ENCLOSURES: CABE s Suggested Policy 4118.235/4218.235 CABE s July 15, 2016 Policy Update REASON: To

More information

The University of Michigan

The University of Michigan Tryout Directions and Information: The University of Michigan This packet contains the following forms that must be completed before your tryout can begin: Tryout clearance form You only need to fill out

More information

Personal Training Health Screening Questionnaire

Personal Training Health Screening Questionnaire RC Health and Fitness, LLC. 10350 Ironbridge Road Chester, VA 23831 (804)248-0222 Personal Training Health Screening Questionnaire Personal Information Today s date: Title: O DR. O Mr. O Mrs. O Ms. Name:

More information

Here are a few resources you may want to refer to in order to learn more about Applied Behaviour Analysis (ABA) and our program:

Here are a few resources you may want to refer to in order to learn more about Applied Behaviour Analysis (ABA) and our program: Dear Parent/Guardian: Thank you for your interest in the St.Amant Autism Programs. Please find enclosed is the application package for the St.Amant Autism Early Learning Program. Here are a few resources

More information

Please everything to the address below: ITEMS TO MAIL. 1. Copy of the athletes immunization record

Please  everything to the address below: ITEMS TO MAIL. 1. Copy of the athletes immunization record In order to participate in the Syracuse Indoor Showcase each player will need to EMAIL all the items below upon completion of their online registration. Your registration/spot in the showcase is not complete

More information

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.

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.

More information

CAMP SOCIAL 2018 ENROLLMENT APPLICATION FOR CAPE GIRARDEAU

CAMP SOCIAL 2018 ENROLLMENT APPLICATION FOR CAPE GIRARDEAU ENROLLMENT APPLICATION FOR CAPE GIRARDEAU Name of Camper: Date of Birth: County: * A separate Enrollment Application and Camper Portfolio must be completed for each child. Parent/Guardian Information Name

More information

Pro Active Physical Therapy & Sports Medicine

Pro Active Physical Therapy & Sports Medicine Pro Active Physical Therapy & Sports Medicine Consent and Statement of Financial Responsibility 1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other

More information

TEAM NECC 2018 Boston Marathon

TEAM NECC 2018 Boston Marathon TEAM NECC 2018 Boston Marathon Contact: Beth McGonagle, Director of Operations bmcgonagle@necc.org 508-658-7571 The New England Center for Children is a private, nonprofit autism research and education

More information

CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL / TTY 847/ FAX 847/

CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL / TTY 847/ FAX 847/ CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL 60062 847/559-0110 TTY 847/559-9493 FAX 847/559-8199 APPLICATION FOR ADULT PROGRAMS IDENTIFYING INFORMATION Date: Name: LAST FIRST MIDDLE Address: City:

More information

Hazlehurst City School District Application for Superintendent of Schools

Hazlehurst City School District Application for Superintendent of Schools Hazlehurst City School District Application for Superintendent of Schools Please type or print your responses and fully respond to each item. I. Basic Information Name (Last) (First) (Middle) Social Security

More information

Operation Screen Your Athlete Medical Questionnaire

Operation Screen Your Athlete Medical Questionnaire Operation Screen Your Athlete Medical Questionnaire PLEASE PRINT Athlete s Name: DOB: / / Male Female Street Address: School Attending: Parent/Guardian Name: Parent/Guardian Email: Parents please fill

More information

STATE OF HAWAII DEPARTMENT OF HEALTH P.O Box 3378 Honolulu, Hawaii August 1, 2009

STATE OF HAWAII DEPARTMENT OF HEALTH P.O Box 3378 Honolulu, Hawaii August 1, 2009 LINDA LINGLE GOVERNOR OF HAWAII CHIYOME LEINAALA FUKINO, M.D. DIRECTOR OF HEALTH STATE OF HAWAII DEPARTMENT OF HEALTH P.O Box 3378 Honolulu, Hawaii 96801-3378 August 1, 2009 Dear Parents: The Hawai i State

More information

Home Assessments Occupational Therapy

Home Assessments Occupational Therapy Home Assessments Free PDF ebook Download: Home Assessments Download or Read Online ebook home assessments occupational therapy in PDF Format From The Best User Guide Database (A subsidiary of the British

More information

North Carolina Board of Physical Therapy Examiners Application for Physical Therapist Licensure

North Carolina Board of Physical Therapy Examiners Application for Physical Therapist Licensure FOR OFFICIAL USE ONLY Name: End: Ex: Rev by End: Exost: Board Approved by: PT Revive by Endorsement Application Examination Date: / / ID Number: / / Exam Form Number: / / SCORES: Scaled: / / Raw: / / NC

More information

Eliada Assessment Center Application for Services

Eliada Assessment Center Application for Services Student s Name: Record # Date of Birth: Race: Biological Sex: Male Female Gender Identity: Male Female Transgender/Non-Binary Date Placement Needed: SSN: - - Legal Custodian: Name, Address, Phone, Email

More information

Appendix C NEWBORN HEARING SCREENING PROJECT

Appendix C NEWBORN HEARING SCREENING PROJECT Appendix C NEWBORN HEARING SCREENING PROJECT I. WEST VIRGINIA STATE LAW All newborns born in the State of West Virginia must be screened for hearing impairment as required in WV Code 16-22A and 16-1-7,

More information

MC IRB Protocol No.:

MC IRB Protocol No.: APPLICATION FORM - INITIAL REVIEW INSTITUTIONAL REVIEW BOARD Room 117 Main Building 555 Broadway Dobbs Ferry NY 10522 Phone: 914-674-7814 / Fax: 914-674-7840 / mcirb@mercy.edu MC IRB Protocol No.: Date

More information

North Carolina Board of Physical Therapy Examiners Application for Physical Therapist Licensure

North Carolina Board of Physical Therapy Examiners Application for Physical Therapist Licensure FOR OFFICIAL USE ONLY Name: End: Ex: Rev by End: Exost: Board Approved by: PT Endorsement Application Examination Date: / / ID Number: / / Exam Form Number: / / SCORES: Scaled: / / Raw: / / NC Passing:

More information

CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL / TTY 847/ FAX 847/

CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL / TTY 847/ FAX 847/ CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL 60062 847/559-0110 TTY 847/559-9493 FAX 847/559-8199 For Office Use Only: Date Received: Admitted: 9 Y 9 N Admission Date: School: 9 Day 9 Res Assessment

More information

Patient Registration Form

Patient Registration Form Patient Registration Form Date: Last Name: First: Middle: Street Address City State Zip Home Phone: Work Phone: Mobile Phone: Date of Birth: Social Security: Sex: Male Female Martial Status: Single Married

More information

Wellness and Chiropractic Industry

Wellness and Chiropractic Industry Wellness and Chiropractic Industry HydroMassage Marketing Plan and Resources 1 About The HydroMassage Marketing Plan and Resources are designed to help you successfully launch HydroMassage in your practice.

More information

Benefit: Hearing Services and Hearing Aid Devices

Benefit: Hearing Services and Hearing Aid Devices CSHCN Services Program Hearing Services Benefits (PACT Transition) Information posted July 31, 2009 Effective for dates of service on or after September 1, 2009, the hearing services benefits for children

More information

Tell Us About Your Child. Who is Accompanying Your Child Today? Parent Information. Primary Dental Insurance

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

More information

Explanation of requirements for clinical experiences HFU

Explanation of requirements for clinical experiences HFU Page 1 Explanation of requirements for clinical experiences HFU Tuberculosis Screening Explanation of Required Immunizations and Health Requirements All nursing students are required to have an initial

More information

CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY!

CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY! 2017-18 Point Park University Athletics Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2017-18 year. Please return all completed

More information

Qualification Form Instructions

Qualification Form Instructions Qualification Form Instructions Congratulations on taking steps toward maintaining or improving your health! The Blue Cross Blue Shield of Michigan qualification form is enclosed for you and your physician

More information

MEMBERSHIP APPLICATION INSTRUCTIONS

MEMBERSHIP APPLICATION INSTRUCTIONS American Dental Association California Dental Association Stanislaus Dental Society MEMBERSHIP APPLICATION INSTRUCTIONS 1. Answer every question completely. Explain items in detail on a separate sheet

More information

Following this letter are health forms for parents or legal guardians to complete and sign. Please note that:

Following this letter are health forms for parents or legal guardians to complete and sign. Please note that: Summer Pre-College Programs Dear Summer Pre-College Student and Family, Welcome to Marist College! Please review the attached Health Forms. Students will be informed of health and emergency information

More information

Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:

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

More information

NORTHWEST PENNSYLVANIA REGIONAL POLICE TESTING CONSORTIUM 2018

NORTHWEST PENNSYLVANIA REGIONAL POLICE TESTING CONSORTIUM 2018 Dear Applicant; Please fill out the attached Preliminary Testing Application Mail the application along with a SIGNED MONEY ORDER for $75 made out to: Mercyhurst University Police Academy NO PERSONAL CHECKS

More information

AUXILIARY AIDS PLAN FOR PERSONS WITH DISABILITIES AND LIMITED ENGLISH PROFICIENCY

AUXILIARY AIDS PLAN FOR PERSONS WITH DISABILITIES AND LIMITED ENGLISH PROFICIENCY AUXILIARY AIDS PLAN FOR PERSONS WITH DISABILITIES AND LIMITED ENGLISH PROFICIENCY PURPOSE This plan provides the policies and procedures for Directions for Living to ensure: A. That all clients and/or

More information

CHISHOLM TRAIL ALLERGY AND ASTHMA PHONE (817) /FAX (817) DUTCH BRANCH ROAD, SUITE 200, FORT WORTH, TX

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

More information

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it

More information

Child s Legal Name: Nickname: Male Female. Birth Date: Age: School: Grade: FATHER STEPMOTHER GUARDIAN? Insured s Name: D.O.B. Social Security #:

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

More information

White Plains YMCA 2016 Summer Camp Registration Form

White Plains YMCA 2016 Summer Camp Registration Form White Plains YMCA 2016 Summer Camp Registration Form Camper Information Child s First Name: Child s Last Name: Date of Birth: Gender: Age: S L XL What grade will your child be entering in the Fall of 2016?:

More information

CONDITIONS OF SERVICES RENDERED

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

More information

APPLICATION FOR EMPLOYMENT-Non Salaried Position CITY OF RALSTON, NEBRASKA EQUAL OPPORTUNITY EMPLOYER

APPLICATION FOR EMPLOYMENT-Non Salaried Position CITY OF RALSTON, NEBRASKA EQUAL OPPORTUNITY EMPLOYER APPLICATION FOR EMPLOYMENT-Non Salaried Position CITY OF RALSTON, NEBRASKA EQUAL OPPORTUNITY EMPLOYER Position Applied For (One application per position required) Last Name (Please Print) First Name (Please

More information

Application for Cadet Membership

Application for Cadet Membership Application for Cadet Membership 275 West Main Street P.O. Box 309 Braidwood, IL 60408 815-458-2000 Name: (Print Neatly) Introduction The Braidwood Fire Department consists of dedicated men and women who

More information

Baa Hózhó Navajo Prep Math Summer Camp 2017

Baa Hózhó Navajo Prep Math Summer Camp 2017 Math Summer Camp 2017 Application Packet Grades 7-12 May 30-June 3, 2017 Navajo Preparatory School, Farmington, NM Residential Camp Application Checklist A complete application must include the following:

More information

Hillsboro Middle School/Hillsboro High School 550 US 62 South Hillsboro, Ohio /

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

More information

Summer Camp Question and Answer Disclaimer

Summer Camp Question and Answer Disclaimer Summer Camp Question and Answer Disclaimer The board members of the Pennsylvania Athletic Trainers Society (PATS) are continually asked questions regarding the operations of summer camps and the liability

More information

HEALING HANDS CHIROPRACTIC, LLC 3 Hall Ave Wallingford, CT healinghandsdc.com

HEALING HANDS CHIROPRACTIC, LLC 3 Hall Ave Wallingford, CT healinghandsdc.com HEALING HANDS CHIROPRACTIC, LLC 3 Hall Ave Wallingford, CT 06492 203-626-9994 healinghandsdc.com Child Intake Form PERSONAL INFORMATION Date Child s Name: Address Gender M F Age Birthdate City State Zip

More information

Family Allergy Clinic

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:

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION 15205 41 st Ave. SE, Bothell, WA 98012-6114 - P.O. Box 13888, Mill Creek, WA 98082-1888 Telephone (425) 337-3647 Facsimile (425) 337-4399 EMPLOYMENT APPLICATION An incomplete application may delay action

More information

Controlled Substances Program. For Academic Units

Controlled Substances Program. For Academic Units Brigham Young University Page 1 Provo, Utah Controlled Substances Program For Academic Units Last Revised: November 30, 2009 Brigham Young University Page 2 TABLE OF CONTENTS Section Title Page 1.0 Overview

More information

Chiropractic Case History/Patient Information

Chiropractic Case History/Patient Information 1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Race: Marital: M S W D Occupation: Office Phone:

More information

PATIENT REGISTRATION FORM

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

More information

Patient Information Form

Patient Information Form Patient Information Name: First Middle Last Address: City: State: Zip: Telephone: Home Cell Work Date of Birth: Social Security Number: (SSN is only needed if getting super-bills for potential insurance

More information

FONTBONNE UNIVERSITY Department of Communication Disorders and Deaf Education

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)

More information

FACT SHEET Q Fever and the Australian Q Fever Register

FACT SHEET Q Fever and the Australian Q Fever Register FACT SHEET Q Fever and the The Bare Facts Q Fever Protection Q Fever is an infectious disease that can cause severe illness in some people. People usually get Q Fever from farm animals (cattle, sheep and

More information

TRUSTLINE REGISTRY The California Registry of In-Home Child Care Providers Subsidized Application

TRUSTLINE REGISTRY The California Registry of In-Home Child Care Providers Subsidized Application State of California-Health and Human Services Agency TRUSTLINE REGISTRY The California Registry of In-Home Child Care Providers Subsidized Application California Department of Social Services Community

More information

Application Package Mental Health First Aid First Nations Co-facilitator Training Course

Application Package Mental Health First Aid First Nations Co-facilitator Training Course Application Package Mental Health First Aid First Nations Co-facilitator Training Course Cultural Safety: Becoming a Mental Health First Aid (MHFA) First Nations Co-facilitator ------------------------------------

More information

APPLICATION EIOH PRECEPTORSHIP PROGRAMS

APPLICATION EIOH PRECEPTORSHIP PROGRAMS Application Date Month Day Year University of Rochester University of Rochester Medical Center Eastman Institute for Oral Health 625 Elmwood Avenue Rochester, New York 14620-2989 USA (585) 275-8315 Paste

More information

Jumpstart, Fitness Assessment, & Body Composition

Jumpstart, Fitness Assessment, & Body Composition Jumpstart, Fitness Assessment, & Body Composition Waiver, Release and Hold Harmless Agreement In consideration of permission granted by Purdue University allowing me to participate in Personal Training

More information

COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH

COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE CHILD S CURRENT HEALTH STATUS DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS TOBACCO/ALCOHOL IF YES, DESCRIBE YOUR DELIVERY: CHILD S HEALTH HISTORY INSTRUCTIONS:

More information

CHAPTER 7 SECTION 24.1 PHASE I, PHASE II, AND PHASE III CANCER CLINICAL TRIALS TRICARE POLICY MANUAL M, AUGUST 1, 2002 MEDICINE

CHAPTER 7 SECTION 24.1 PHASE I, PHASE II, AND PHASE III CANCER CLINICAL TRIALS TRICARE POLICY MANUAL M, AUGUST 1, 2002 MEDICINE MEDICINE CHAPTER 7 SECTION 24.1 ISSUE DATE: AUTHORITY: 32 CFR 199.4(e)(26) I. DESCRIPTION The Department of Defense (DoD) Cancer Prevention and Treatment Clinical Trials Demonstration was conducted from

More information

Baby-Sitting - $20 Per Day/Per Nanny (local clients) Less than 24 hours notice $30 Per Day/Per Nanny. Hotel Overnight Sitting - $35 per Day/Per Nanny

Baby-Sitting - $20 Per Day/Per Nanny (local clients) Less than 24 hours notice $30 Per Day/Per Nanny. Hotel Overnight Sitting - $35 per Day/Per Nanny ALL ABOUT NANNIES BUSINESS PHONE: 602-266-9116 BUSINESS FACSIMILE: 602-266-9787 BUSINESS EMAIL: ADMIN@ALLABOUTNANNIESINC.COM TEMPORARY, BABY-SITTING, HOTEL & ON-CALL AS NEEDED Mother s Full Name: Place

More information