ARTHRITIS & RHEUMATOLOGY OF GA, PC

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ARTHRITIS & RHEUMATOLOGY OF GA, PC GARY MYERSON, MD PAUL SUTEJ, MD PAULA TANASA, MD ANNA ADAMS, PA-C CASHELLE ROSE, PA-C NEW PATIENT REGISTRATION FORM (Please Print) Patient Information Patient s last name: First name: Middle: Circle one: Mr. Mrs. Ms. Dr. Street Address: Marital Status: S M W D Date of Birth: Sex: M F P.O. Box City: State Zip Home phone # Alternate phone # Email Address: Occupation: Employer: Employer Phone #: Referring Physician Phone #: Primary Care Physician Phone #: Spouse: Phone #: Emergency Contact: Phone #: Primary Insurance: Insurance Information Policy Holder s name (if other than self) Policy Holder s D.O.B Policy # Group # Secondary Insurance: Policy Holder s name (if other than self) Policy Holder s D.O.B Policy # Group #

Privacy Policies and Office Policies I agree to the Privacy Policies (HIPPA) and Office Policies of Arthritis and Rheumatology of GA. I understand that a full copy of both the Privacy Practices and Office Policies are available to me at the office and at our website www.argmd.net. Patient Contacts I/We authorize this medical practice to leave messages or discuss my PHI with the names listed below: (Include name and relationship) Phone: Phone: Records may be forwarded to: Referring Physician Primary Care Physician Other Provider(s) please list Additional Physician: Phone: Additional Physician: Phone: Patient Signature: Date: Pharmacy: Pharmacy Name Retail Pharmacy Specialty Pharmacy Phone Number Past Medical History: Please check all involved; complete to the best of your ability. Allergies Anemia Angina Anxiety Arthritis Asthma Atrial Fibrillation Blood Clots Cancer COPD Coronary Artery Disease Depression Diabetes Elevated Lipids Gallbladder Disease GERD Headache, Migraine Hepatitis/Liver Disease Hypertension Irritable Bowel Disease Myocardial Infarction Osteoporosis Renal Disease Seizure Disorder Stroke Thyroid Disease Other

Comments: (Year, complications, other): Past Surgical History: Please check all involved; complete to the best of your ability. Angioplasty Appendectomy Arthroscopy Back Surgery Blood Transfusion CABG Cardiac Pacemaker Cataract Extraction Cholecystectomy Colectomy Colostomy Gastric Bypass Hernia Repair Hip Replacement Knee Replacement LASIK Mastectomy ORIF Thyroidectomy Tonsillectomy Other Carpal Tunnel Release Hysterectomy Comments: (Year, complications, other): Immunizations (Approximate date if known): PPD: / / Flu: / / Hepatitis B: / / Pneumonia: / / Family History/Illness: Please check all family history of Rheumalogical diseases; complete to the best of your ability Ankylosing Spondylitis Bechet s Crohn s Gouty Arthritis Juvenile Arthritis Nephritis Osteoporosis Polymyositis Psoriatic Arthritis Raynaud s Rheumatoid Arthritis Sarcoidosis Sjorgren s Syndrome Systemic Lupus Thyroid Disease

Social History: Have you ever been a smoker? Cigarettes: /day Cigars: /day Pipe(s): /day Have you ever tried to quit smoking? Year? Have you ever lived with a smoker? Alcohol: /day Caffeine Intake (coffee, tea, cola, Etc.): /day Drugs (Marijuana, other): Bones: Previous Fractures: please indicate what area/and year: DXA Scans (Bone Density) and date: Previous Arthroplasty- (Joint Replacement): yes no Please indicate the Body Prosthesis (Body Joint) - location and year: Please list previous surgeries: PLEASE LIST ALL CURRENT MEDICATIONS TAKEN: Include all prescription and over the counter medicines. Name Dose Frequency

Medication ALLERGIES and Symptoms: Completed By: DATE: Authorization to Treat: I consent to examination, treatment and procedures which may be performed during my office visits including emergency treatment considered necessary by the physician and/or his designated provider. Assignment of Insurance: I hereby assign payment directly to Arthritis and Rheumatology of GA, P.C. for services covered by insurance or other health benefit plans. Authorization for Release of Information: I authorize ARG to release to my insurance carrier and its designated agents any medical information, including information related to psychiatric care, drug and alcohol abuse, and HIV/AIDS, necessary to process any healthcare related review or quality assurance activities. I also authorize the release of medical information to other healthcare providers who provide consultative services regarding my healthcare. This authorization remains in effect until revoked by me in writing. I agree that a photocopy of the same is as valid as the original. Patient/Guardian signature Date

ARTHRITIS AND RHEUMATOLOGY OF GA, PC 980 JOHNSON FERRY RD NE, STE 220 ATLANTA, GA 30342 PHONE: 404.255.5956 FAX: 404.528.1858 Directions to Northside Hospital Doctors Centre: Directions Traveling East on I-285 Exit #26 at the Glenridge Connector and turn right at the foot onto Glenridge Drive. Merge into the left hand turn lane, and turn left at the light onto Johnson Ferry Road. The Doctors Centre is on your left after crossing the bridge and before the next intersection. Turn left into the Doctors Centre, the 960 Building is on the left and the 980 Building is on your right. Parking is immediately ahead in the garage. The current cost to park is $6.00. Directions Traveling West on I-285 Exit #28 at Peachtree-Dunwoody Road and turn left onto Peachtree Dunwoody Road. Turn right at the fourth traffic light onto Johnson Ferry Road, in front of Northside Hospital. Pass Northside Hospital on the right, Scottish Rite on your left. The Doctors Centre is on your right, passing through the next traffic light. Turn right into the Doctors Centre and drive straight ahead for the parking garage. The 980 Building is on your right as your drive in. The current cost to park is $6.00. Directions from GA 400 (North and South) Traveling North take exit 4A and turn left onto the Glenridge Connector. Turn right at the light onto Johnson Ferry Road. The Doctors Centre is on your left before the Hospital. Traveling South- Take exit #3 and turn left onto the Glenridge Connector. Turn right at the light onto Johnson Ferry Road and the Doctors Centre is ahead on your immediate left. The parking deck is immediately ahead in the garage and the current cost to park is $6.00. ***Please be aware it is $6.00 cash, check, or card to park within the parking deck. This is regulated by a third party and not under our control. Thank you for your understanding. ***

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