HISTORY AND INTAKE FORM

Similar documents
PATIENT REGISTRATION (Please Print)

Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one. Primary Address: Street # Street name Apt# City State Zip

F M S M W D. Age Birth Date Gender Marital Status Cell Phone

Intake and History Form

Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone

Patient or Parent/ Guardian Signature Date

PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:

NAME DATE Page 1. Other. Kidney Removed (Right, Left) Bladder Removed. Ovaries Removed for Endometriosis Breast Biopsy

PATIENT INFORMATION. RESPONSIBLE PARTY (If Different from Patient) POLICY HOLDER INFORMATION (If Different from Patient)

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

San Luis Dermatology & Laser Clinic, Inc.

If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:

Preferred Pharmacy. Past Medical History

Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL. Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed

Is there any person (including your spouse) that you would like medical information released to? If so please give the following information:

Michael J. Huether, M.D., P.C. Arizona Skin Cancer Surgery Center, P.C. History and Intake Form. Patient Name D.O.

TO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU.

DERMATOLOGY AND COSMETIC MEDICINE SPECIALISTS Jay D. GeIler, MD FAAD FASD FASDS Deborah Petrowsky, MD Elizabeth Walsh, PA-C

CYNTHIA B. YALOWITZ, M.D., F.A.A.D.

Patient Registration Form

Dermatology-Dermatologic Surgery- Aesthetic and Cosmetic Dermatology

Intake and History Form

Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:

Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:

Dermatology Medical History

Consent to Treat, Medical Release of Information Notice, and Agreement to Pay Notice. Date of Birth:

Dermatology Medical History

Past Skin History (Please check the applicable boxes to the patient s history or choose the first box)

ADULT INFORMATION SHEET

MedDerm Associates, Inc.

Patient Registration Form : PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code:

Thank you for selecting our practice. Please download all the attached forms, complete and bring them with you to your appointment.

Patricia C. McCormack, M.D., F.A.A.D.

PATIENT DEMOGRAPHIC FORM. address: Primary Care Information Primary Care Physician: Ref. Physician (if different):

INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY

Patient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code:

CHESTERFIELD VALLEY DERMATOLOGY

6140 W Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)

Retinal Consultants of San Antonio PATIENT REGISTRATION

HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**

ARTHRITIS & RHEUMATOLOGY OF GA, PC

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

Medical History Record

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

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

NEW PATIENT HEALTH HISTORY

BLUEGRASS DERMATOLOGY Patient Registration Form

PATIENT NAME DATE. Wendy A. Epstein, M.D., F.A.A.D. Board Certified Dermatologist (Cellular Dr. Epstein)

Patient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code:

Three Rivers Ayurveda-Patient Medical History

Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )

Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information

Vanguard Rheumatology Partners REGISTRATION FORM (Please Print)

PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?

PATIENT INFORMATION FORM

Phone (Mobile): Phone (Home): Phone(Work): Name: Relationship: Phone: Name: Phone: Zip Code:

We are an academic institution What does that mean?

Patient Name: Date of Birth: Date of Visit (Today s Date): Date of Injury (if applicable): Occupation: Right or Left Handed: Referring Provider:

Notto Chiropractic Health Center Patient Information

New Patient Paperwork

New Patient Intake Form

FROST FAMILY MEDICINE

Adult Health History for New Patient

311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship

HEADACHE HISTORY FORM

Which physician are you scheduled to see? Scheduled Appointment Date: As a reminder: Please arrive minutes prior to your scheduled appointment.

Lehigh Valley Physician Group

Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive Florence, Alabama

Patient Registration Form

Initial Clinical History and Physical Form

EMERGENCY CONTACT INFORMATION: Name of contact: Address: Phone#: Relationship: May we release medical information to this person?

Drs. Paul and Anita Gill PATIENT REGISTRATION. Address: City/State/ Zip: Marital Status: Emergency Contact: Phone Number:

Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone

Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:

WELCOME Patient Registration Date:

- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )

Patient Information Form

Name: DOB: Sex: Male Female

Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:

Adult Health History

Steven J. Smith Kingwood Dr., BLDG. 6 Kingwood, Texas 77339

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.

Access Endodontics Marat Tselnik, DDS -PRACTICE LIMITED TO ENDODONTICS-

Clinical Genetics Service

Last Name First Name MI SS# DOB. Address. City State Zip. Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell)

PATIENT MEDICAL HISTORY

Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:

PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:

GUPTA SPORTS & SPINE CENTER

Patient Registration Form

PATIENT REGISTRATION

Patient Name: 1831 N. Belcher RD Suite C3 Clearwater, FL Phone: Fax: Authorization to Release Protected Information Da

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:

3 Flr Scotia Centre, Calgary, AB T2P 2W3 DR. KATHRYN DOYLE, ND! Phone: Fax: !!!!! Naturopathic Doctor! Adult Intake Form!

Name Date of Birth PLEASE COMPLETE ALL PAGES AND ITEMS -- THANK YOU.

Admission Form. Dr. Na Zhai Clinic 1200 S. 5th Street Springfield, IL Please call for help:

Transcription:

PATIENT NAME: HISTORY AND INTAKE FORM DOB: DATE: Asthma Atrial fibrillation Bone marrow transplantation Breast cancer Colon cancer COPD Coronary artery disease (heart disease) Diabetes End stage renal disease (kidney) Hepatitis (A, B, or C) Hypertension (high blood pressure) HIV / AIDS Hypercholesterolemia (high cholesterol) Artificial joints which joint/s: Basal cell carcinoma surgery Colectomy (inflammatory bowel disease) Coronary artery bypass Heart transplant PTCA (percutaneous transluminal coronary angioplasty) Kidney removed (right, left) Kidney transplant Acne Actinic keratoses (precancer lesions) Basal cell skin cancer Blistering sunburns Eczema Hay fever / allergies PAST MEDICAL HISTORY PAST SURGICAL HISTORY Hyperthyroidism (high thyroid level) Hypothyroidism (low thyroid level) Leukemia Lung cancer Lymphoma Pacemaker Prostate cancer Radiation treatment Rheumatoid arthritis Seizures Stroke Valve replacement Ovaries removed Prostate removed Mastectomy Melanoma surgery Spleen removed Squamous cell carcinoma surgery Hysterectomy; uterine cancer or fibroids SKIN DISEASE HISTORY Melanoma Precancerous moles (atypical moles) Psoriasis Squamous cell skin cancer Do you wear sunscreen? 9 Yes 9 No SPF #: Do you tan in a tanning salon? 9 Yes 9 No Do you have a family history of melanoma? 9 Yes 9 No If yes, which relative(s)? Any other pertinent family history? POS Reorder # 1524939

Referring Physician: Phone Number for Referring Physician: Primary Physician: Phone Number for Primary Physician: MEDICATIONS MEDICATION: DOSAGE: HOW OFTEN: REASON FOR TAKING: (Please PRINT all current medications) (Please enter all allergies) MEDICATIONS YOU ARE ALLERGIC TO SOCIAL HISTORY (Please circle all that apply) Cigarette Smoking: Never smoked Quit: former smoker Smokes less than daily Smokes daily - if yes, how many? Alcohol use: Less than one drink per day One to two drinks per day Three or more drinks per day What is your occupation? Pharmacy Name: Address: POS Reorder # 1524940

PATIENT REGISTRATION (Please Print) DATE: PATIENT INFORMATION Patient s Name: SS #: (First) (Middle) (Last) Street Address: Apt. #: Male 9 Female 9 Age: Patient s Date of Birth: Home ( ) Cell ( ) Email Address: Marital Status: Married 9 Single 9 If Married, Name of Spouse: If Child - Name of Mother and Father or Legal Guardian: Person Responsible for bill if different than patient: Name: SS #: (First) (Middle) (Last) Street Address: Apt. #: Home ( ) Cell ( ) D.O.B. Age: Primary Insurance Name of Insurance: Subscriber Name: INSURANCE INFORMATION Secondary Insurance Name of Insurance: Subscriber Name: Subscriber s Date of Birth: Sex: Subscriber s Date of Birth: Sex: Policy or ID #: Policy or ID #: Group #: Group #: POS Reorder # 1524938

ANNUAL MEDICAL CONSENT The patient is responsible for providing this office with the correct insurance information, a CURRENT REFERRAL for the services that are to be performed, and any insurance updates. I understand the above statement and agree that I will be responsible for the total charges incurred if I fail to comply with this request, including any charges not covered by my insurance. I authorize Drs. Jeffrey P. Callen, Carol L. Kulp-Shorten, Jyoti B. Burruss, Kristin O. Donovan, Shannon M. McAllister, Alfred L. Knable, Timothy S. Brown, Anna A. Hayden, Cindy E. Owen, Courtney R. Schadt, Sonya K. Burton, Michael W. McCall, Jr., M. Tye Haeberle, and nurse practitioners Susan E. Elrod, Bridget G. Hart, Kathryn A. West-Pfingston and physicians assistants Elizabeth Morton and Mitzi Carter to release information for the purpose of payment, treatment and routine healthcare operations and including medical research studies. I authorize payment of medical benefits to Drs. Jeffrey P. Callen, Carol L. Kulp-Shorten, Jyoti B. Burruss, Kristin O. Donovan, Shannon M. McAllister, Alfred L. Knable, Timothy S. Brown, Janine C. Malone, Anna A. Hayden, Soon Bahrami, Cindy E. Owen, Courtney R. Schadt, Sonya K. Burton, Michael W. McCall, Jr., M. Tye Haeberle, and nurse practitioners Susan E. Elrod, Bridget G. Hart, Kathryn A. West-Pfingston and physicians assistants Elizabeth Morton and Mitzi Carter. Pursuant to Kentucky Revised Statutes (KRS 411.195), if your account requires the use of an attorney to recover the amount you owe, either by legal action or by other means, you will be responsible for payment of reasonable attorney fees and court costs. Further, if we are required to turn your account over to a collection agency, you will be responsible for those charges as well. All medical records created, sent or received by this office in connection with the services to be performed will be stored and maintained in an electronic form. Upon conversion of any paper or other record to an electronic form, the original record will be discarded through shredding or other permanent disposal. I understand the above statement and agree that my medical records can be stored and maintained electronically. X (signature) (date) POS Reorder # 1524942

ASSOCIATES IN DERMATOLOGY, PLLC RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT I have received a copy of the Privacy Practices provided by Associates in Dermatology, PLLC. Print Patient s Name Date of Birth Signature of Patient / Parent or Guardian Date My Protected Health Information may be disclosed to: 9 Self 9 Spouse / Significant Person Responsible for bill if different than patient: 9 Parent / Guardian 9 Roommate 9 9 Children I give permission for Associates in Dermatology to contact or leave a message regarding test results on the following: 9 Home Phone Voice Mail Home # 9 Cell Phone Voice Mail Cell # 9 Work Phone Voice Mail Work # PHARMACY MEDICATION HISTORY RELEASE Please initial below if Associates in Dermatology has permission to pull your pharmacy fill history. (initials) POS Reorder # 1524941

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback