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

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

Preferred Pharmacy. Past Medical History

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

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

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

San Luis Dermatology & Laser Clinic, Inc.

Patient Registration Form

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

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

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

Intake and History Form

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

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

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

Patient or Parent/ Guardian Signature Date

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

Intake and History Form

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

PATIENT REGISTRATION (Please Print)

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

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 #:

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

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

Dermatology-Dermatologic Surgery- Aesthetic and Cosmetic Dermatology

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

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

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

HISTORY AND INTAKE FORM

Name DOB Date. Past Surgical History

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

Dermatology Medical History

Dermatology Medical History

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

BLUEGRASS DERMATOLOGY Patient Registration Form

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

Patient Information. Insurance Information

Medical History Record

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

Retinal Consultants of San Antonio PATIENT REGISTRATION

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

CHESTERFIELD VALLEY DERMATOLOGY

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

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

HEADACHE HISTORY FORM

PATIENT INFORMATION FORM

PATIENT REGISTRATION

NEW PATIENT REGISTRATION FORM

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

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

Laser Vein Center Thomas Wright MD Page 1 of 4

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

INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY

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

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

GUPTA SPORTS & SPINE CENTER

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

Premier Dermatology & Cosmetic Surgery Information Sheet

3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:

SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:

Adult Health History for New Patient

PATIENT DEMOGRAPHIC SHEET

Premier Dermatology & Cosmetic Surgery Information Sheet

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

New Patient Information. Which Physician will you be seeing today? How did you hear about our practice?

Address: City: State: Zip:

Providence Medical Group

PATIENT INFORMATION. Are we currently seeing one of your family members at our practice, or have we previously? YES patient s name:

Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:

FROST FAMILY MEDICINE

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

SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:

Sonoma Skin Dermatology - 1 Appointment Date: 3/19/2013 Name: Nickname: DOB: Age: Gender: Female Male Marital Status: S M D W O

New Patient Medical History Form

Adult Demographics Form

Who is filling out this intake form? Self Spouse Parent Guardian

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )

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

Health History Questionnaire

Primary Care Clinic Adult Patient Demographics

Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?

Mailing Address: Street City Zip

Patient Name Date of Birth Age. Other phone ( ) . Other

ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS

PLAS/RECON SURGERY PATIENT HEALTH HISTORY

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

Name: DOB: Sex: Male Female

Last: First: MI: Nickname:

DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)

Welcome to Dr Jamie Italiane-DeCubellis s office

UROLOGY CENTER OF PALM BEACH, P.A.

PATIENT INFORMATION Please print clearly and complete all blanks

Patient Interview Form

Adult Health History

Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:

DATE OF BIRTH: MELANOMA INTAKE

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

Transcription:

For office use only: EMA Centricity Insurance Patient Registration Form : PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code: Race: Ethnic Group: Preferred Language: Marital Status : Single Married Divorced Widowed Employer/Place of Employment : (if retired list previous profession) Social Security Number: Spouse Name (if applicable) Caretaker Name (if applicable) Cell Phone: Home Phone: Work Phone: Email Address: Medical Information Release (Dermatologists of Greater Columbus Privacy Policies are located at the reception desk) May we leave a message for you to return our call? May we leave a message for you to return our call? May we leave a message for you to return our call? Circle your preferred contact method Cell Home Work ***IF you would like text messages sent to your cell phone for appointment reminders please text: DSWO to 622622 If you are not available may we leave a message with another person? If yes, please state below: Name/Relationship Phone Emergency Contact: Name/Relationship Phone Pharmacy: *our office does electronic prescriptions please list as much information as possible* Name: City & Zip code: Phone: Have you ever been seen by one of our physicians? (if yes, physician name) Primary Care Provider: Full Name: Location: _ Phone: Fax: Did your Primary Care Provider refer you? Were you referred by another physician? Yes No Name of referring Provider How did you hear about our office (check all that apply)? Internet Radio Yellow Pages TV Newspaper Friend Relative Doctor Signature of Responsible Party: Date:

Dermatologists of Greater Columbus Thank you for choosing Dermatologists of Greater Columbus. The following is our financial policy. Please review the policy, initial where indicated, sign and date at the bottom. Paperwork: We request you routinely update your paperwork to ensure we have all the correct information on hand for billing purposes and to ensure excellent clinical care. This paperwork allows us to bill insurances in a timely manner and from preventing balances being unnecessarily transferred to you, the patient. We understand the frustration of completing paperwork and are constantly evaluating different methods to reduce the burden on you. Missed appointments/cancellations: We request 24 hour advanced notification of cancellations and reschedules. We try to notify all patients of upcoming appointments using our computerized calling system. Unfortunately, we do experience errors with the system from time to time. We do not charge for missed appointments or cancellations. Frequently missed appointments and cancellations can result in dismissal from our practice. Insurance: Our practice is contracted with most commercial insurances and Medicare. We do not accept Medicaid. As a contracted provider, we agree to accept adjusted fees from your insurance company and bill in accordance with CPT and ICD guidelines. We collect co-pays at the time of visit. Deductibles and other outstanding balances will be billed to you, after your claim has been processed by your insurance company. We are unable to determine prior to your visit what charges will be applied to your deductible. The patient is responsible for providing the most up to date insurance information prior to, or at the time of service. Patient is responsible for payment of services rendered in the event they incorrect insurance information was provided at the time of service. Available forms of payment include: cash, check, MasterCard, and Visa. We Do Not accept Discover or American Express. Cosmetic Procedures: Payment is expected in full at the time of your procedure. Lab Fee: Dermatologists of Greater Columbus and Dermatologists of Southwest Ohio use an outside laboratory for pathology services. When possible the practice will bill for the laboratory services. Patient is Responsible for Total Charge: Patients will be billed in full for any unpaid copayments or deductibles. Patient balances will be set by the adjusted rates as determined by our contract with your insurance company. In accordance with our contracts and Medicare guidelines we cannot make adjustments to these fees or the codes charges. If your insurance requires a referral and the necessary referral was not obtained prior to services rendered the patient (or party responsible for billing as listed below) is responsible for total payment of services rendered. Prompt payments is expected. Insurance Information: Initial Does your insurance require a referral? If yes please list all physician information on page 1 Primary Insurance Insurance Name/Phone: Insurance Effective Date Subscriber s Policy Number Group No. Specialty Co-Pay $ Subscriber s Name, Relation and Address (if different from patient) Subscriber s Date of Birth _ Subscriber s SSN Secondary Insurance Insurance (Secondary) Insurance Effective Date Insurance Phone: Subscriber s Policy Number Group No. Specialty Co-Pay $ Subscriber s Name, Relation and Address (if different from patient) Subscriber s Date of Birth _ Subscriber s SSN Person Responsible for Payment if Other than Patient Billing Name SSN Date of Birth Phone Number Relationship to Patient Employer Address Recent Insurance policy changes and the popularity of high deductible plans have increased the number of bills and balances to patients. If you have not met your deductible for your plan year, please expect a bill from our office. Per our insurance contracts we are unable to make adjustments to any outstanding balance. My Signature below indicates that I have read and agree to the above written financial policy of Dermatologists of Greater Columbus. Signature of Responsible Party Date

Patient Information Name: Date of Birth: Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplant BPH (benign prostatic hyperplasia) Breast Cancer Colon Cancer COPD Coronary artery disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Medical Symptoms: Please check all the apply Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung cancer Lymphoma Prostate cancer Radiation Treatment Seizures Stroke Appendix: (appendectomy) Bladder: (cystectomy) Breast: Breast Biopsy Breast: Lumpectomy (both breasts) Breast: Lumpectomy (left breast) Breast: Lumpectomy (right breast) Breast: Mastectomy (both breasts) Breast: Mastectomy (left breast) Breast: Mastectomy (right breast) Colon (colectomy): Colon Cancer Resection Colon (Colectomy): Diverticulitis Colon (Colectomy): Inflammatory Bowel Colon: Colostomy Gallbladder: (cholecystectomy) Heart: Biological Valve Replacement Heart: Coronary Artery Bypass Heart: Heart Transplant Heart: Mechanical Valve Replacement Heart: PTCA (angioplasty) Acne Actinic Keratosis (pre skin cancer) Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Have you had any of the following procedures: Please check all the apply Joint Replacement: Hip (both) Joint Replacement: Hip (left) Joint Replacement: Hip (right) Joint Replacement: Knee (both) Joint Replacement: Knee (left) Joint Replacement: Knee (right) Kidney: Kidney Biopsy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Nephrectomy Liver: Hepatectomy Liver: Liver Transplant Liver: Shunt Ovaries: (oophorectomy): Endometriosis Ovaries: (oophorectomy): Ovarian Cancer Ovaries: Tubal Ligation Pancreas: Pancreatectomy Prostate: (prostatectomy): Prostate Biopsy Prostate: (prostatectomy): Prostate Cancer Have you had any of the following conditions: Please check all that apply Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Prostate: (prostatectomy): TURP (transurethral resection) Rectum: APR (abdominal perineal resection) Rectum: Low anterior resection Skin: Basal Cell Carcinoma Skin: Melanoma Skin: Skin Biopsy Skin: Squamous Cell Carcinoma Spleen: (splenectomy) Testicles: (orchiectomy) Uterus: (hysterectomy): Fibroids Uterus: (hysterectomy): Uterine Cancer Uterus: (hysterectomy): Cervical Cancer Do you wear sunscreen? Do you tan in a tanning salon? If Yes, what SPF? Do you have a family history of melanoma? If yes, which relative? Have you had the pneumonia vaccination? if Yes what year?

Latex allergy? Any drug allergies? If yes, list any drugs you are allergic to: Medications (list all prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary supplements as well as name/dosage/freq/route) Medication Name Dosage Frequency Route Alcohol: None Less than 1 drink/day 1-2 drinks daily 3 or more drinks daily Social History: Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? Tobacco Products Use? Current every day smoker Former every day smoker Never Have you ever tested positive for TB? How many times in the past year have you had 5 or more drinks in a day for men, or 4 or more drinks in a day for women or any adult older than 65? (please list an approximate number in the space provided) Problems with bleeding Problems with healing Problems with scarring (hypertrophic or keloid) Abdominal Pain Anxiety Bloody Stool Bloody Urine Blurry Vision Chest pain Cough Depression Dizziness Fever or Chills Grey Discoloration of Skin Hay Fever Headaches Immunosuppression Joint Aches Review of Systems: History or current problem with any of the following? Please check all that apply Menstrual changes Muscle Weakness Neck Stiffness Night Sweats Rash/Hives Seizures Shortness of Breath Sleeplessness Sore Throat Thyroid Problems Unintentional Weight loss Vaginal Candidiasis Wheezing Red Eye Tearing Eyes Eye Pain Uncontrolled Blood pressure Elevated Blood Sugar Ebola Risk: Allergy to adhesive Allergy to Lidocaine Allergy to topical antibiotic ointments Artificial heart valves Artificial joints in the last 2 years Blood thinners Defibrillator MRSA Pacemaker Pregnant or planning a pregnancy Premedication prior to procedures (If Yes why?) Rapid heartbeat with epinephrine Prostate medications Transplant West Africa: Travel or contact Fever greater than or equal to 100.4 degrees (F) / 38.0 degrees Resided or Traveled to a country with wide-spread Ebola transmission in the last 21 days Contact with an Ebola Patient without proper protective equipment in the last 21 days Headaches, weakness, muscle pain, vomiting, diarrhea, abdominal pain and/or hemorrhage Signature of Responsible Party: Date:

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