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.

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Dear New Patient, Thank you for choosing Dennis M. Lox, M.D to participate in your healthcare. We realize that you could have chosen any other office, so we are honored that you have chosen us. While Dr. Lox has cared for thousands of patients since starting his practice in 1990, we treat each of our patients as individuals and attend to their unique needs. Attached is an initial intake questionnaire, designed to make your initial visit much more efficient. Please do your best to complete each section of the questionnaire so that we can have as much information about you as possible. Our office is located at 2030 Drew Street, Clearwater FL, 33765. We are on Drew Street, in between N.E Old Coachman Road and Hercules Avenue. If you have any questions before your appointment, please feel free to contact our office via telephone; 727-462-5582, via email;, fax; 727-462-5583. Again, thank you for choosing Dr. Lox and we look forward to meeting you!

Today s Date: Social Security Number: Name: Date of Birth: Employer: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Email Address: Emergency Contact: Phone #: Relationship To You: In the event of an emergency, may we release your medical information to this person? YES NO May we leave a voicemail on your answering machine to confirm your appointment? YES NO Primary Care Physician: Phone: Fax: INSURANCE INFORMATION PRIMARY: Insurance Carrier: HMO or PPO Referrals Required? YES NO Member Identification Number: Group Number: Claims Address (PO BOX on back of card): Policy Holder: Relationship: D.O.B: Deductible: Copay: SECONDARY: N/A Insurance Carrier: HMO or PPO Referrals Required? YES NO Member Identification Number: Group Number: Claims Address (PO BOX on back of card): Policy Holder: Relationship: D.O.B: Deductible: Copay:

Patient Name: Date of Birth: Age: Height: Weight: Chief Complaint: Are you currently taking any anticoagulants? YES or NO Current Prescribed Medications: Allergies: Are you allergic to any of the following? Aspirin Lidocaine Betadine / Iodine Tape Latex Social History: Occupation: Marital Status: S M D Children: Yes No If Yes, How Many: Tobacco Use: YES NO Nutrition: Currently On A Diet? Yes No Explain: Past Medical History: Have you ever had or currently have cancer? NO YES radiation chemotherapy (please circle) If Yes, Please Specify: Breast Prostate Other: Radiology: (Most Recent) XRAY/MRI DATE: XRAY/MRI DATE: Surgical History YEAR Knee Shoulder Hip Lumbar explain: Cervical explain: Other: Chronic Medical Problems (Please Circle) Hypertension Diabetes Gout Asthma Arthritis Renal Disease Thyroid Disease Coronary Heart Disease COPD Family History (Please Circle) Cancer Hypertension Hyperlipidemia Diabetes Coronary Artery Disease Arthritis OA RA RF Disorders Lupus How did you hear about Dr. Lox? (Please Circle) RADIO INTERNET DOCTOR PATIENT TELEVISION OTHER

Authorization for Medical Treatment And Assignment of Benefits Patient Name: Date: I, the undersigned patient, authorize Dennis M. Lox, M.D to carry out such examinations and diagnostic procedures, and to administer such treatments as may be deemed medically necessary or advisable. I hereby certify that I have read and fully understand the above authorization for medical treatment and diagnostic procedures. (if necessary) Further, I assign directly to Dennis M. Lox, M.D all medical insurance benefits otherwise payable to me for ALL services rendered. I understand that I am fully responsible for ALL charges, whether or not covered by my insurance. I hereby authorize Dennis M. Lox, M.D to release any of my personal information necessary to secure payment of benefits. I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS ON MY BEHALF. Patient Signature Signature of Legal Guardian/Resp Party (if under 18) Patient Printed Name Printed Name of Legal Guardian/Resp Party

Clearwater,Florida Authorization to Release Medical Records Today s Date: Patient Name: Patient Date of Birth: Last 4 Digits of Patient SSN: Doctor / Medical Facility: Address: Phone Number: Fax Number: I authorize the healthcare provider/facility named above to release a copy of my medical records to include all office notes, films and diagnostic test results and forward them to: Dennis M. Lox, M.D 2030 Drew Street Clearwater, FL 33765 Phone: 727-462-5582 Fax: 727-462-5583 This authorization is valid for one year from the date above. Patient Signature OR Witness Signature of Legal Guardian or Responsible Party (under 18)

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