• New Patient Information Form

  • DOB *
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Sex:*
  • Marital Status:*
  • Format: (000) 000-0000.
  • Date Last Saw PCP?
     - -
  • Consent to leave confidential information by phone, text, email, mail, or voicemail containing detailed medical information on the phone number(s) provided. This information may include, but not limited to, demographic information (partial or full name, date of birth, address, etc.), billing information, medical information (diagnosis, medications, test results, etc.). *

  • Information of Insurance Policy Holder

    (if self, skip section)

  • DOB
     - -
  • Format: (000) 000-0000.

  • Social History

  • Tobacco Use?*
  • Alcohol Use?*
  • How often?*
  • Illicit/Recreational Drug use?*

  • Medical Questions 

  • Diabetic?*
  • Last Diabetic Foot Check date?
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  • Date last seen:
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  • Are you allergic to any of the following?*
  • Do you have any previous medical history?*
  • Are you currently taking any medications?*
  • Have you ever had any surgeries?*
  • Do you have any family history of medical conditions?*
  • How would you describe your OVERALL HEALTH:*
  • Ever been hospitalized?*
  • Any implantable devices?*
  • Do you have any concerns regarding SAFETY at home?*
  • Household smoke detector?*
  • Firearms in home?*
  • If yes, are they locked in a safe place?
  • In a relationship?
  • For a relationship, I prefer:
  • Sexually active?
  • Any Form of Contraception?
  • Describe OVERALL DIET: *
  • Regular EXERCISE ROUTINE?:*
  • Do you consume CAFFEINE?*
  • Do you consume JUICE OR SODA?*

  • In the last year visited:

  • DENTIST? *
  • EYE DOCTOR? *
  • Have you seen a dermatologist for a yearly skin exam?*
  • Do you have an ADVANCED DIRECTIVE/LIVING WILL/DPOA on file?*
  • History of HIGH CHOLESTEROL?*
  • Ever been treated for it?*
  • History of HIGH BLOOD PRESSURE? *
  • Ever been treated for it?*
  • History of DIABETES or PREDIABETES? *
  • Ever been treated for it?*
  • Feeling down, depressed or hopeless?*
  • Have you lost interest or pleasure in doing things?*
  • Check if you have completed the following vaccines:*
  • Covid
  • Covid Booster
  • Would you like STD screening (mainly for Gonorrhea, Chlamydia, Syphilis, or HIV)? *
  • History of being tested for HEPATITIS or exposure to someone with hepatitis?*
  • Have you ever been screened for lung cancer by a low dose CT-scan? *
  • Have you completed a colonoscopy in the past?*

  • FOR MALES:

  • Ever been screened for prostate cancer?*
  • Ever been screened for an abdominal aortic aneurysm?*

  • FOR FEMALES:

  • Do you have periods?*
  • Date of last menstrual period?*
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  • Taking oral contraceptives?*
  • Pregnant or Trying to get pregnant?*
  • Breastfeeding?*
  • Nursing?*
  • Have you ever completed a pap smear test?*
  • Abnormal or HPV positive?*
  • Colposcopy test completed?*
  • Have you ever completed a mammogram?*
  • If 65 years or older, have you completed a DEXA scan?*
  • Have you completed a colonoscopy in the past?*

  • Office Policies

  • Referral Process
    It may be necessary for our office to refer you to a specialist to manage your care. In order for a referral to be made, you must be evaluated first in our office. If you need to request a referral from us, phone us at least one week prior to your appointment. As part of the referral process, we may need to share your medical information with another provider or specialist. Your privacy is protected as only minimal information is shared.

    Medication Refills
    Please bring your medications to your appointments. Should you need refills prior to your next appointment, first call your pharmacy. They can request a refill from our office. Please give us at least 1 week notice prior to your medication running out, 2 weeks’ notice if it is a mail-order pharmacy. Pain medicines may require an appointment.

    Billing
    Please bring your insurance card(s) to each visit. All co-pays and deductibles are the patient’s responsibility and expected to be paid on the day of service prior to being evaluated by the provider.

    • If a patient has a no-copay/high-deductible plan, then the patient is expected to pay $65 that will go towards their office visit at the time of service or, if known by the provider, the full contracted insurance rate for the office visit at the time of service.
    • If the patient needs the provider to complete paperwork (e.g. FMLA paperwork) outside of an office visit, then a $35 fee is required for completion.

    Scheduling Appointments
    Patients are seen by appointment only, except in the case of an emergency, which may cause delays. We ask for your understanding, knowing that if you ever require urgent care, we will give you prompt attention. To schedule appointments, please call (330) 422-4377. In the event that you are unable to keep your appointment time, please call at least 24 hours in advance to reschedule. There will be a $50 charge for no show appointments. If you miss 2 or more appointments due to a “no show” appointment, your chart will be reviewed and you may be discharged from this practice.

    Hospital/Emergencies
    If you have a life threatening illness, call 911 or go to the nearest Emergency Room and have a family member call our office.

    After Hours/On Call Policy
    Our office hours are Monday through Friday 9am-5pm. For urgent request, please contact our main office number rather than Spruce. If it is an urgent request and we are unable to address your concern, please go to the emergency department as soon as possible. For non-urgent request, you can leave a message for staff to be returned within the next 3-5 business days. 

    UH Twinsburg Urgent Care - 8819 Commons Blvd., Suite 101, Twinsburg, Ohio 44087 P: 234-837-5418 

    Cleveland Clinic Emergency Department - 8701 Darrow Rd, Twinsburg OH 44087 P:330-888-4176

     

    By signing on the next page, I agree to the above policies

  • Please read and sign at the bottom to agree to the following statements:

    I hereby authorize the release of medical information to insurance carriers, referring providers, and healthcare systems concerning my illness and treatment, when necessary. I hereby assign to the doctor all payments for medical services rendered to me or my dependent. I understand I am responsible for any amount not covered by insurance.

    Acknowledgement of Treatment
    I request and authorize Dr. Aarondeep Deol, Dr. Nazmine Deol, staff, and resident physicians, to perform general treatments and procedures as may be deemed necessary in my care.

    Notice of Privacy Practices Acknowledgement
    I, the undersigned, acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read, or have been offered a copy, and understand the notice (available upon request).

    Medicare One Time Direction of Payments
    If applicable, I give my permission to ask for Medicare payments for my medical care. I understand that Medicare needs information about me and my medical condition to make a decision about these payments. I give permission for that information to go to Medicare and the companies that handle Medicare payment requests. I understand that the Health Care Financing Administration (HCFA) is the government Medicare agency.

     

    By Signing here, I state that the above information has been answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient’s) health.

  • Date*
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  • Should be Empty: