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

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! Page 1 of 5 PATIENT INFORMATION: NAME (Nombre): DATE OF BIRTH (Fecha de Nacimiento): ADDRESS (Direccion): CITY (Ciudad): STATE(Estado): ZIP(Codigo Postal): TELEPHONE (HOME)(# Casa): CELL(# Celular): WORK(Numero de Trabajo): SOCIAL SECURITY # (# Seguro Social) - - DRIVERS LICENSE #: STATE: EMPLOYER: OCCUPATION: EMPLOYER ADDRESS: ZIP: INJURY DATE: MARITAL STATUS (circle) S M D W SEX: M / F E-MAIL ADDRESS: PATIENT PORTAL: May we contact you through our Patient Portal Website?: Yes No INSURANCE INFORMATION: POLICY HOLDERS NAME: RELATIONSHIP: ADDRESS: CITY: STATE: ZIP: SOCIAL SECURITY #: - - DATE OF BIRTH PHONE: PRIMARY INSURANCE: ID# GROUP# SECONDARY INSURANCE: ID: GROUP# MEDICARE # MEDICAID # REFERRED BY: TELEPHONE #: PHARMACY INFORMATION: NAME: TELEPHONE # EMERGENCY CONTACT INFORMATION: Name of contact: Address: Phone#: Relationship: May we release medical information to this person? YES NO

Page 2 of 5 MEDICARE ASSIGNMENT FOR COVERED SERVICES I CERTIFY THE INFORMATION GIVEN IN APPLYING FOR PAYMENT IS CORRECT AND REQUEST PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF.. ASSIGNMENT OF INSURANCE BENEFITS I HEREBY AUTHORIZE PAYMENT TO JUAN P. VELAZQUEZ M.D., FOR MEDICAL SERVICES. I REPRESENT THAT I HAVE INSURANCE COVERAGE AND DO HEREBY AUTHORIZE JUAN P. VELAZQUEZ M.D., TO RELEASE AND OBTAIN ALL INFORMATION NECESSARY TO SECURE PAYMENT OF SAID BENEFITS. IF MY INSURANCE FAILS TO PAY JUAN P. VELAZQUEZ M.D., FOR ANY REASON I AGREE TO PAY ALL UNPAID BALANCES. I HAVE READ AND UNDERSTAND MEDICAL SERVICES DISCLOSURE, MEDICARE ASSIGNMENT, AND ASSIGNMENT OF INSURANCE BENEFITS AND AGREE TO ALL TERMS STATED. I ACKNOWLEDGE THAT THE NOTICE OF PRIVACY PRACTICES HAS BEEN MADE AVAILABLE TO ME IN THE LOBBY. PAYMENT IS EXPECTED A THE TIME THAT OFFICE SERVICES ARE RENDERED. THANK YOU. SIGNATURE: DATE: NEW PATIENT HISTORY (age 4 and older) NAME: DATE: PATIENT HISTORY

Page 3 of 5 NASEL/SINUS ALLERGIES HIGH BLOOD PRESSURE EPILEPSY ASTHMA HEART ATTACK URINARY INCONTINANCE EMPHYSEMA (C O P D) HEART MURMMUR KIDNEY STONES ECZEMA CONGESTIVE HEART FAILURE ERECTILE DYSFUNCTION RHEUMATOID ARTHRITIS HIGH CHOLESTEROL ABNORMAL PAP SMEAR OSTEOARTHRITIS ALCOHOLISM UTERINE FIBROIDS DEEP VEIN BLOOD CLOTS ANXIETY ENDOMETRIOSIS DIABETES DEPRESSION OVARIAN CYSTS HYPOTHYROIDISM (low thyroid) STROKE CANCER (list type): MIGRAINE HIV/AIDS NONE OTHER CONDITIONS: (PLEASE LIST) SURGICAL HISTORY SKIN BIOPSY CHOLECYSTECTOMY (GALLBLADDER) HERNIA REPAIR HYSTERECTOMY (UTERUS ONLY) HYSTERECTOMY BSO (UTERUS AND OVARIES) SPINAL SURGERY BREAST BIOPSY APPENDECTOMY NONE TUBAL LIGATION (TUBES TIED) TONSILLECTOMY TYMPANOSTOMY (EAR TUBES) VASECTOMY WISDOM TEETH HEART BYPASS CORONARY ARTER STENT CESAREAN SECTION OTHER: (PLEASE LIST) IMMUNIZATION HISTORY PLEASE LIST TETANUS (Td or TDaP) Year: Don t know HEPATITIS B (three shot series) Year: Don t know MMR/MEASLES Year: Don t know PNEUMONIA VACCINE (Pneumovax) Year: Don t know HPV VACCINE (Guardasil) Year: Don t know SHINGLES (Zostavax) Year: Don t know TUBERCULOSIS (TB) TEST (PPD) Year: Don t know HAVE YOU HAD CHICKENPOX? Year: Don t know NEW PATIENT FAMILY HISTORY (age 4 and older) NAME: DATE: FAMILY HISTORY ASTHMA MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER:

Page 4 of 5 DIABETES MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: HEART ATTACK MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: HIGH CHOLESTEROL MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: HYPERTENSION MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: STROKE MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: DEPRESSION MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: BREAST CANCER MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: COLON CANCER MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: MELANOMA MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: OVARIAN CANCER MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: PROSTATE CANCER MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: OTHER CANCER MOTHER FATHER BROTHER SISTER SON DAUGHTER OTHER: OTHER CONDITIONS (PLEASE LIST): MEDICATIONS CURRENTLY TAKING: NAME DOSE NUMBER OF TIMES PER DAY 1 2 3 4 5 6 7 8 9 10 DO YOU TAKE ANY VITAMINS? YES NO DO YOU TAKE ANY NATURAL SUPPLEMENTS? YES NO ALLERGIES CIRCLE ALL THAT YOU HAVE: PENICILLIN LATEX SULFA NONE: OTHER:

Page 5 of 5 REQUEST FOR MEDICAL RECORDS Date: Patient Name: DOB: SSN: I request that all records to be sent to the following physician. Dr. Juan P. Velazquez, MD 6601 Blanco Rd Suite 100 San Antonio, TX 78216 Phone: (210) 541-0018 Fax: (210) 541-0024 If you have any questions please call our office during business hours: Monday thru Friday 8AM 5PM. Thank you for your prompt attention. Note: If more than five pages, please mail to Address above. Please provide as much information, if possible, for the following: Name of Physician/Clinic: Address: City: State: Zip Code: Phone: Fax: SIGNATURE: Patient or Parent/Guardian Date

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