Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
By entering I agree to receive medical and information emails from Apogee Medical Association.
Email
example@example.com
SSN #
*
Marital Status
Married / Remarried
Divorced
Widow (er)
Gender
Male
Female
N/A
Other
Race
Please Select
American Indian or Alaskan Native
Asian
Middle-East
Black or African-American
South or Central American Indian
Native Hawaiian or Pacific Islander
Native Caribbean or Atlantic Islander
White (European or other)
Ethnicity
Back
Next
Emergency Contact Information
Emergency Contact Information
First Name
Last Name
Relationship to Patient
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Guarantor Information
(Responsible Party for bills, IF OTHER THAN PATIENT)
Guarantor's Name
First Name
Last Name
Guarantor's Date of Birth
-
Month
-
Day
Year
Date
Guarantor Relationship to Patient
Self
Parent
Spouse
Other
Child (Over 18+)
Guarantor's Phone#
Please enter a valid phone number.
Format: (000) 000-0000.
Guarantor's Cell#
Please enter a valid phone number.
Format: (000) 000-0000.
Guarantor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Primary Insurance
Name of Primary Insurance
Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Number
Effective Date
-
Month
-
Day
Year
Date
Group Number
Copay $
Name of Secondary Insurance
Secondary Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Policy Number
Effective Date
-
Month
-
Day
Year
Date
Group Number
Copay $
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Medical History
Today's Date
-
Month
-
Day
Year
Date
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Current Medication
Current Medication: Please list dose and frequency if known
Past Medical History
Past Medical History
Heart Attack
Diabetes Mellitus
Cancer
Peripheral Artery Disease
Thyroid Problems
High Blood Pressure
High Cholesterol
Chest Pain
Mitral Valve Prolapse
Kidney Trouble
Coronary Artery Disease
Angina
Heart Murmur
Epilepsy/Seizures
HIV/AIDS
Stroke
Ulcers
Hepatitis
Tumors
Asthma
Other
Pacemaker
Yes
No
Date of Implant
-
Month
-
Day
Year
Date
Make or Model
Allergies
Allergies to Medicine
Allergies to Food(s) or Other(s)
Back
Next
Surgical History
If you do not recall day or month it is okay. Please be as accurate as possible.
Date and what kind of surgery
Hospitalization
If you do not recall day or month it is okay. Please be as accurate as possible.
Date and Why
Family Medical History
Father
Living
Diabetes
Deceased
Heart Disease
Hypertension
Other
Mother
Living
Diabetes
Deceased
Heart Disease
Hypertension
Other
Son(s)
Living
Diabetes
Deceased
Heart Disease
Hypertension
Other
Daughter(s)
Living
Diabetes
Deceased
Heart Disease
Hypertension
Other
Brother(s)
Living
Diabetes
Deceased
Heart Disease
Hypertension
Other
Sisters)
Living
Diabetes
Deceased
Heart Disease
Hypertension
Other
Social History
Smoking
Yes
No
Former Smoker
Amount
Duration
Alcohol
Yes
No
Former
Amount
Duration
Non-Prescription Drugs
Yes
No
Former
Name of Drug
Amount
Duration
Back
Next
Authorizations
*If yes, please provide a copy to the staff
Do you have an Advance Directive and/or Living Will?
Yes
No
Persons Authorized to Receive your Protected Health Information, if any:
Name(s) & Relationship(s)
Financial Responsibility
PATIENT PAYMENT RESPONSIBILITY = I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL OFFICE AND HOSPITAL COPAYS, DEDUCTIBLES, AND COINSURANCES, FEES ARE DUE AT THE TIME OF SERVICE.
AUTHORIZATION AND ASSIGNMENT= I HEREBY ASSIGN MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO CHITRADEEP DE, MD. I AUTHORIZE CHITRADEEP DE, MD TO RELEASE ANY INFORMATION NECESSARY TO REQUEST CLAIM REIMBURSEMENT FROM MY INSURANCE CARRIERS.
Signature
*
Patient or Authorized
Submit
Should be Empty: