New Patient Registration Forms English

Patient Name

Are you here today due to an injury from a MOTOR VEHICLE ACCIDENT OR WORK-RELATED *

***If you answered YES, please see the receptionist before continuing to complete this form.*** Yes No

Do you have or had any of the following? (check box )

Have you been hospitalized in the past?
YesType a label NO Type a label SURGERY (reasons) Type a label Other medical conditions blanks
Childbirth: Natural Type a label C-sectionblank

Have you ever use tobacco in any form?

yes NO- Go to next questions Cigarettes Pipe Cigar Snuff/Skoal chewing Other

Tobacco Use
When did you start ? blanks How much do / did you use daily? blank if you have quit, when did you quit? Type a label .

Have you ever used Alcohol in any form

Yes No Beer Wine Liquor

Alcohol Use
When did you start ? blanks How much do / did you use daily? blank if you have quit, when did you quit? Type a label .

Have you ever used Recreational drugs in any form

Yes No Marijuana LSD Cocaine Heroin Meth Pills Other

Recreational Drugs Use
When did you start ? blanks How much do / did you use daily? blank if you have quit, when did you quit? Type a label .

Do you have Allergies

Please list your medications, vitamins, supplements: ( name of medication, How do you take it, Written by:)

What pharmacy do you use( Name of Pharmacy)

Pharmacy Address

Do you have an Advance Directive? Yes or No blanks .
Do you have an Advance Directive indicate" Do Not Resuscitate? Yes or Noblank
Do you have a Durable Power of Attorney? Yes or No Type a label If yes please provide a copy.

Do you have a family history of chronic diseases or premature death?

Is there anything else you'd like the doctor to know about your medical history, social history or general condition that may help him deliver better care to you?

Patient Name

Patient DOB

OFFICE POLICIES

Main Office Hours Monday & Wednesday 7:30 AM 4:30 PM Tuesday & Thursday 8:00 AM-SPM Friday's 7130 AM 12 NOON

We are glad you have chosen us to provide you with your medical needs. We have adopted the following policies, if you have any questions please discuss them with the office manager. We are dedicated to providing the best possible care for you and your family.

1.APPOINTMENTS This office is an appointment only office. You need to schedule an appointment in order to see the physician. If you arrive earlier you will only be seen sooner if there is an opening. NO WALK INS ALLOWED. NEW PATIENTS -Confirmation is required no later than 24 hours before the appointment to avoid cancellation.

2. PAYMET FOR SERVICE - Unless other arrangements have been made in advance, we require payment at the time of service. We accept cash, checks,Visa, Master card and Care Credit ONLY!

3. INSURANCE We have made prior arrangements with many health plans to accept an assignment of benefits. This means we will bill those plans with which we are contracted.

4.THIRD PARTY INS We do not accept third party insurance (i.e. automobile insurance- if involved in an auto accident, or Letter of Protection- payment directly from a law office If you are involved in any of these cases, you will be required to pay the office visit in full, and be reimbursed by your third party.

5. MINORS - All minors must be accompanied by an adult over 18 years old. For all services rendered to minor patients, the adult accompanying the patient will be held responsible for payment, unless prior arrangements have been made.

6. NO-SHOWS In order to ensure that all appointments available are being used, we do charge a $50.00 fee for "NO SHOWS" and/or APPOINTMENTS that are NOT canceled 24 HOURS prior to the scheduled appointment time. Acquiring (3) NO SHOWS may result in termination from the practice.

7. PRESCRIPTIONS If you require a refill on your medications, please call your pharmacy, they will contact us. The providers write your prescriptions with enough refills to last until you are due for follow up. If you are out of refills, you may be due for a follow up. The only exception is if you require a triplicate prescription. All controlled medications require a current Toxicology Screen. Please allow 48-72 hours for refills so we may review your chart. PAPER PRESCRIPTIONS - will only be written if required by the DEA. Otherwise, there will be a $5 charge if not necessary.

8.REFERRALS All HMOs require a referral by your PCP, if you need to see a specialist. Please allow up to 72 hours, depending on your insurance plan, to process the referral.

9. FMLA Family Leave and Disability Forms, Sports/Work Physical Forms and/or any professional Letters, will require a $40.00 administration fee, and is paid up front. These are not covered by your insurance company. Please allow 7-10 business days for completion after your payment.

10. MEDICAL RECORDS - If you would like copies of your medical records there is a $25.00 fee for the ist 20 pages, and $0.50 for each additional page. As a courtesy, there is no charge for transferring your medical records directly another to physician's office for continuity of care.

11. AFTER HOUR CARE If you require medical care after office hours, simply call our office and you will be forwarded to an answering service. Depending on the situation, the Dr. will be paged. You will always have access to your Doctor.

12. LATE APPOINTMENTS- If you arrive late to your scheduled appointment, you will be worked back into the schedule if there is availability. If there is no availability you will be asked to reschedule. Any patient that shows up after 11:30am will be asked to return to our office at 1:00 pm to be worked back into the schedule, due to the lunch hour. If you arrive after 4 pm, your appointment will be rescheduled.

13. PRE- OP APPOINTMENTS- In order to ensure your surgery is completed, your pre-op appointment has to be scheduled at least 1 week prior to the surgery date. All testing (pre-op labs ordered by PMA, chest x-ray, surgeon orders) are to be completed before you are able to schedule an appointment. Testing is only valid for 30 days from the of the surgery date, so please make sure you complete all testing within that time frame.

14. RIGHT TO REFUSE SERVICE- Verbal abuse to any of our doctors or staff will not be tolerated. Foul language and or aggressiveness will lead to immediate termination of your patient/doctor relationship and therefor instates our right to refuse service to you. I have read and understand the office policies listed above.

Patient/Guardian Signature

Clear

Date

Office use only: Initial of Employee