Last Name First Name MI SS# DOB. Address. City State Zip. Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell)
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1 39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA South 9 th Street, 1 st Floor Philadelphia, PA Last Name First Name MI SS# DOB address Address City State Zip Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell) Race Ethnicity (Hispanic/non-Hispanic) DECLINE Preferred Language Gender Marital Status Employer Occupation Pharmacy Name Pharmacy Phone # Emergency Contact Name Phone # Relationship Address Insurance Information: Please provide a copy of your insurance card Insurance Subscriber (if not self): Subscriber DOB: Subscriber Address Relationsip Are you capitated to a certain lab? Referral Information Referred BY (circle) Doctor Website Insurance PENN Referral Line Primary Care/ Family Doctor Phone # *I hereby authorize the release of medical information necessary for the processing of my medical/ laboratory claims. I authorize payment to Gynecology Specialists of Philadelphia LLC. I take full responsibility for payment for all services rendered. A photocopy of this authorization is as valid as the original. * I have received a copy of GSP Privacy & Office Policies. I have read and agree to comply with these policies. Patient Signature Date
2 Name DOB Medical History: Have you had the following? High Blood Pressure Heart Attack Depression High Cholesterol Stroke Anxiety Diabetes Blood Clot (lung) Seizures Anemia Blood Clot (leg) Migraines Hyperthyroidism Bowel Obstruction Kidney Failure Hypothyroidism Crohn s Disease Kidney Stones Breast Cancer Ulcerative Colitis Sarcoidosis Cervical Cancer Irritable Bowel (IBS) Sickle Cell Disease Ovarian Cancer GERD (Acid Reflux) Lupus Uterine Cancer Hepatitis B Rheumatoid Arthritis Asthma Hepatitis C Gallstones Sjogren s syndrome Emphysema Anorexia/ Bulimia Other Surgical History: Please list name and date of procedure if possible Medications: Name Dose Times per day Allergies: No Known / Unknown
3 Name DOB Chief Complaint/ Reason for Visit: Gynecologic History: First day of your last period Date of your last GYN exam Any abnormal pap tests? Yes/ No Date of last mammogram Any abnormal mammograms? Yes/ No Have you had 3 Gardasil Vaccines? Yes/ No List any GYN problems you have or had in the past (i.e. Fibroids, endometriosis, PID, cysts, ETC) Contraceptive History: What are you using for birth control? Circle all that apply None tubal ligation vasectomy pills Nuva Ring condoms IUD Other Any problems with contraception now or in the past? Obstetrical History: How many pregnancies have you had? How many children delivered? Vaginal or C-Section Miscarriages Abortions Ectopic or Tubal Pregnancies Family History: Does anyone in your family have cancer? Yes/ No Please list who has/ had cancer and what type: Social History: Do you smoke? Yes/ No Drink alcohol? Yes/ No Use other drugs? Yes/ No Caffeine? Yes/ No Are you sexually active? Yes/ No If yes, with men women both Have you ever had a sexually transmitted disease (STD)? Yes/ No If yes, what did you have? Were you treated? Yes/ No
4 OFFICE POLICIES There are many practices you could have chosen for your gynecologic care. We would like to take the time to thank you for choosing Gynecology Specialists of Philadelphia. It is our desire to provide personalized, compassionate, top-notch care to all of our patients and understand it is important that play an active role in their health care. To that end, we believe our patients should have a full understanding of our office policies, expectations and procedures so as to optimize your experience with us. Please take time to read the information outlined below. Our office accepts routine phone calls from 8:30 am 4:15 pm Monday-Thursday and 8:30 am 2:30 pm on Friday. Please make non-emergency calls during these hours so that we have access to your medical records and can better serve you. INSURANCE: There are numerous insurance plans available therefore, it s impossible for our staff to know the covered benefits of each plan. It is YOUR responsibility to know and understand the policies and benefits of your plan including referrals, authorizations, co-payments, deductibles, covered hospitals, labs and x-ray (radiology) facilities. APPOINTMENTS: We will make every effort to schedule your appointment in an appropriate time frame. YEARLY WELL-WOMAN EXAMS will be scheduled within ONE TO THREE MONTHS of calling. Scheduling these routine exams in that time frame is important in order to allow patients with urgent medical needs to be seen in a shorter time frame. If you are due for your well-woman exam and have an urgent problem, we will make two appointments for you an earlier appointment for the problem and a later appointment for the well-woman exam. Due to the nature of our practice, we occasionally need to reschedule an appointment you have made and appreciate your understanding should this be the case. We ask that you give 24 hours notice if you need to reschedule. FIRST TIME OFFICE VISITS: Please arrive 15 minutes early for your appointment to allow enough time to complete your registration forms. Please bring a list of all current medications. If this is a consult, please be sure your referral has been sent (if required) and bring any appropriate reports and lab results. LABORATORY: All lab tests performed in the office (pap smears, cultures, biopsies) are processed and billed to you by outside laboratories. We do not draw blood at our office. We will provide you a lab slip and bloodwork should be done at Quest or LabCorp according to your insurance coverage.
5 TEST RESULTS: Some test results may be reviewed with you over the phone. Others may require a follow up appointment to discuss. This decision is made at the discretion of your provider. **Most results take approximately 2-3 weeks to return to our office this includes pap smears, cultures, blood work, biopsies and most radiology studies including routine mammograms. If you have not heard from our office within that time frame, please contact the office. TELEPHONE: One of our providers is on-call every evening, including weekends, for emergencies. The answering service takes all calls after hours. Routine prescriptions (ie: birth control), appointment scheduling/confirmation/cancellations and reviewing of test results will not be handled after hours. We cannot treat patients over the telephone. If you feel you have a true medical emergency, please call 911 or go to the nearest emergency room. PRESCRIPTION REFILLS: If you contact our office for a prescription refill, please have the medication name and your pharmacy phone number ready. There is a 24 hour turnaround for refill requests. If you need a prescription refilled before the weekend, please call ahead to allow time to process your request. We cannot refill medications after hours or on weekends. OFFICE VISIT PUNCTUALITY: We value all of our patients and we appreciate that your time is precious. Our goal is that we are as punctual as possible and see you for your appointment in a timely manner. However, circumstances arise on a daily basis which compromise our ability to be punctual. It is our hope that you will be as understanding as possible with the demands on our staff, especially due to surgical emergencies which require the providers to attend to patients in the hospital or emergency room throughout the day. Our intention is to provide all of our patients with the utmost in medical care. We hope that you will be understanding of these dynamics as they are an inherent part of any gynecology practice which affect our punctuality. Thank you! 39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA South 9 th Street, 1 st Floor Philadelphia, PA
6 I HAVE READ AND AGREE TO COMPLY WITH GYNECOLOGY SPECIALISTS OF PHILADELPHIA OFFICE POLICIES. Printed Name of Patient Signature of Patient Date The undersigned certifies that she has received a copy of Notice of Privacy Practices (NPP) and is the patient, or is the patient s personal representative, Printed Name of Patient or Personal Representative Relationship Signature of Patient Date
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Dear New Patient: Thank you for selecting Meridian Women s Health as your medical provider. In order to provide the very best and most efficient care please complete the enclosed forms describing your
Jeri Shuster, M.D., P.A.
Please help us to help you by completing this health history form. We will review together at your first visit. Included is potentially relevant Ob-Gyn, Medical, Surgical, and pertinent family history.
PATIENT INFORMATION FILL OUT ALL ITEMS
PATIENT INFORMATION FILL OUT ALL ITEMS FAILURE TO COMPLETELY FILL OUT THIS FORM MAY RESULT IN YOU BEING BILLED IN FULL Patient Last Name: First: MI:. Address:. Date of Birth: Gender: M or F Marital Status:
PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
ALLERGIES. If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: MEDICATIONS
Name: Birthdate: What is your main health concern today? Do you currently use tobacco? YES NO Have in the past? YES NO Year Quit If yes, what kind of tobacco?_number of years: Amount of tobacco per day:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (PLEASE FILL OUT COMPLETELY) ****************************************************************************** LAST NAME: FIRST NAME: MI: ADDRESS: CITY: STATE: ZIP: PHONE # S: HOME:
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
ADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
Adult Health History for NEW Patients
Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is
PATIENT INFORMATION. Name Maiden Name Last First MI. Sex: M F Age Birthdate SSN - - Martial Status. Address
PATIENT INFORMATION Date Name Maiden Name Last First MI Sex: M F Age Birthdate SSN - - Martial Status Address City State Zip Home Phone Cell Phone Email Address Contact preference: Race Preferred Language
We look forward to seeing you. Please feel free to call us with any questions.
1227 E. 9th Street Edmond, OK 73034 Phone: (405) 475-0100 Fax: (405) 475-9275 https://susandimickmd.com Welcome to Dr. Dimick s Office. We appreciate the opportunity to provide your health care needs.
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:
311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship
Robert Antonelle, M.D. White Plains Gastroenterology 311 North Street, Suite 403 White Plains, NY 10605 Patient Demographics Patient s Last Name First Name Middle Initial SSN Date of Birth Age Gender F
PATIENT INFORMATION. RESPONSIBLE PARTY (If Different from Patient) POLICY HOLDER INFORMATION (If Different from Patient)
PATIENT INFORMATION Today s Date: Patient s Last Name: First: M.I. Mailing Address: City: State: Zip: Home Phone: ( ) Cell: ( ) Work: ( ) Date of Birth: / / Age: Sex: SSN: Driver s License #: Marital Status: