Clone of Dr. V Health Registration Form

Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
What is your gender?

FemaleMale
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address

Please list your preferred pharmacy:*

	Pharmacy Information
Name
Address
Phone Number

Check the conditions that apply to you:

AsthmaCancerHypertensionDiabetesHypothyroidismPsychiatric disorderEpilepsyOther
If other, please specify:
Check the symptoms that you' re currently experiencing:

Chest painBreathing problemsHeart problemsCirculation problems (blood vessels)Blood disordersSwollen lymph nodesNerve problems (numbness, weakness, seizures)Mood or mental health concerns (anxiety, depression, etc.)Stomach or digestion problemsUrinary or kidney problemsWeight gainWeight lossJoint or muscle painOther
Please describe your symptoms:
Are you currently taking any medication?*

YesNo
If yes, please list all medications/supplements below (name, dose and frequency)
Do you have any medication allergies?*

YesNoNot Sure
If yes, please list any allergies and reaction below:
Please list all previous surgeries if any including year:

Please indicate if any family members (parents, siblings, or children) have a relevant medical history:

	Alive	Deceased	Relevant Medical History
Mother
Father
Siblings
Children

Do you use any kind of tobacco/vape or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever

Please specify when was the last time you had the following test/exam

	Month/Year
Physical Exam
Eye Exam
Colonoscopy
Endoscopy
Pap Smear
Mammogram

Gynecological Hx

	Please be specific
Last menstrual period
Menopause
Full term pregnancies
Premature deliveries
Vaginal deliveries
C sections
Miscarriages/abortions

CONSENT TO RELEASE HEALTH INFORMATION TO A RELATIVE:

I do not authorize anyone else to receive my health information.I authorize the release of my health information to the person indicated below.
Please indicate name and relationship of authorized person
To receive the following information (check all that apply):

Lab resultsMedicationsAppointmentsBillingTreatmentAll of the above
CONSENT TO TREATMENT

I voluntarily consent to receive medical and health care services provided by Valledor Health, PLLC d/b/a MediMission Medical Center (“MediMission”), including its physicians, employees, associates, assistants, and other health care providers, as deemed necessary by my treating physician. I understand that such services may include diagnostic procedures, examinations, and treatment.

I acknowledge that photographs, videos, digital, and/or other images may be taken or recorded for purposes related to my treatment and billing only. I understand that no warranty or guarantee has been made regarding the outcome or cure of my condition.

I also acknowledge that MediMission may use secure health information exchange systems to electronically transmit, receive, and/or access my medical records, including treatment history, prescriptions, laboratory results, and other relevant health information.

This consent shall remain in effect until I revoke it in writing.
Signature

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RELEASE OF MEDICAL INFORMATION

I acknowledge that protected health information may include sensitive data such as mental health (except psychotherapy notes), substance use, HIV/AIDS status, lab results, prescriptions, and treatment history.

I understand MediMission may use or disclose my information as outlined in the Notice of Privacy Practices.

HIPAA Consent

I understand that I may request and receive a copy of the Notice of Privacy Practices from MediMission Medical Center at any time. I consent to the use and disclosure of my health information for treatment, billing, and healthcare operations. I understand that I may request restrictions on how my information is used, and that I may revoke this consent in writing at any time.

FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS

I assign to MediMission my rights to insurance or third-party benefits and authorize direct payment to them. I agree to pay charges not covered by insurance.
Signature

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ELECTRONIC COMMUNICATION AND SIGNATURE CONSENT

I authorize MediMission Medical Center to communicate with me via email, text message (SMS), and/or automated phone calls regarding my healthcare. This includes, but is not limited to, appointment reminders, test results, treatment follow-ups, prescription notifications, and billing matters. I understand that electronic communication may not be
completely secure, but the clinic will use reasonable safeguards to protect my privacy.

Furthermore, I consent to the use of electronic signatures for all medical forms and documents related to my care. I understand that my electronic signature has the same legal
effect as a handwritten signature and is valid under applicable federal and state laws. I may revoke this consent at any time in writing.
Signature

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