TRP PATIENT REGISTRATION FORM CUROGRAM

CLINIC LOCATION
Other
PATIENT INFORMATION
First Name
Last Name
Date of Birth

MonthDayYear
Date
DATE

MonthDayYear
Date
SOCIAL SECURITY NO
SEX
MARITAL STATUS
ETHNICITY
LANGUAGE SPOKEN (Primary)
LANGUAGE SPOKEN (Secondary)
HOME PHONE
Format: (000) 000-0000.
CELLPHONE
Please enter a valid phone number.Format: (000) 000-0000.
OTHER Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL ADDRESS
example@example.com
Address

MAILING ADDRESS

Street Address Line 2

CITYSTATE

ZIP
SPOUSE NAME
SPOUSE SOCIAL SECURITY NO
SPOUSE DOB

MonthDayYear
Date
EMERGENCY CONTACT INFORMATION (NOT LIVING IN THE SAME HOUSEHOLD)
CONTACT NAME
CONTACT PHONE
Format: (000) 000-0000.
RELATIONSHIP
PATIENT EMPLOYMENT INFORMATION
PATIENTS EMPLOYER
WORK NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMPLOYERS ADDRESS
CITY STATE ZIP
ATTORNEY INFORMATION (IF APPLICABLE)
ATTORNEY'S NAME
ATTORNEY'S NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
DATE OF INCIDENT

MonthDayYear
Date
CHIEF COMPLAINT
WHERE & HOW THE INCIDENT OCCURRED
WHEN DID THE PAIN START
HAVE YOU SEEN ANY OTHER PROVIDER FOR THIS INJURY?
IF YES, WHICH PROVIDER?
IF SO, WHAT HAS BEEN PRESCRIBED
INSURANCE INFORMATION (IF APPLICABLE)
PRIMARY INSURANCE
POLICY HOLDER NAME
MEMBER ID
GROUP ID
SECONDARY INSURANCE
MEMBER ID
GROUP ID
PRIMARY CARE PHYSICIAN (PCP)
PCP NAME
PCP PHONE NO.
Format: (000) 000-0000.
MEDICATIONS

Type a question

Rows	NAME	DOSAGE (mg)	Satisfied	Any thoughts?
MEDICATION
MEDICATION
MEDICATION
MEDICATION
MEDICATION

PLEASE CHECK ALL THAT APPLIES:
OTHER CONDITIONS NOT LISTED:
PAST SURGICAL HISTORY (PLEASE CHECK ALL THAT APPLY)
PLEASE LIST OTHER SURGERIES NOT LISTED:
SPINE SURGERY LOCATIONS:
JOINT SURGERY/REPLACEMENT, LOCATIONS:
SOCIAL HISTORY (PLEASE CHECK ALL THAT APPLY)
OCCUPATION:
HOW MANY PACKS PER DAY?
TOBACCO USE
OTHER TOBACCO PRODUCTS:
HOW MANY DRINKS PER WEEK?
ILLICIT SUBSTANCE(S):

Rows	FATHER	MOTHER	OTHER	Please specify other
HYPERTENSION/HIGH BLOOD PRESSURE
HEART ATTACK
OTHER HEART DISEASE
CONGENITAL HEART CONDITION, STROKE OR BLOOD CLOT
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASE
ASTHMA
BLOOD DISORDERS
ARTHRITIS
ALZHEIMER'S DISEASE OR DEMENTIA
DIABETES
HIGH CHOLESTEROL
CYSTIC FIBROSIS
SEIZURES
MIGRAINES
DEPRESSION
OTHER:

PATIENT NAME
Date of Birth

MonthDayYear
Date
DATE

MonthDayYear
Date
I hereby consent to treatment by the attending physician and other medical staff for all local anesthetics, test, surgical and other medical procedures as deemed necessary by myself and the medical staff.

AUTHORIZATION FOR RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS

I hereby assign to the above-named office, those benefits otherwise payable to me by any third party as reimbursement of expenses and fees in connection with treatment rendered. I request that payment of authorized benefits be made directly to the medical provider named above on my behalf.

I FULLY UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY AND ALL AMOUNTS NOT OTHERWISE PAID BY MY INSURANCE CARRIER.

I certify that the information about me to be released to the Health Care Finance Administration or other health care coverage entity, any information needed for this or any related health care claim in writing or verbally. I further understand and agree to pay for services or amounts due when appropriate. These charges could include amounts applied to my annual deductible co-payment amounts, and charges denied as not covered by my insurance program or deemed medically unnecessary. I understand that well care is not covered by Medicare or many other health insurance programs. I hereby authorize release of my films and/or medical records as needed for subsequent medical care. In the event of positive findings, I authorize my attending physician to release the results of my biopsy-surgery to my referring physician named above for their records. If someone other than the patient is signing this authorization, please state relationship with patient and the reason patient is unable to sign.
Information reviewed and verified on

MonthDayYear
Date
Signature
Should be Empty:

CLINIC LOCATION

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION (NOT LIVING IN THE SAME HOUSEHOLD)

PATIENT EMPLOYMENT INFORMATION

ATTORNEY INFORMATION (IF APPLICABLE)

INSURANCE INFORMATION (IF APPLICABLE)

PRIMARY CARE PHYSICIAN (PCP)

MEDICATIONS

PLEASE CHECK ALL THAT APPLIES:

PAST SURGICAL HISTORY (PLEASE CHECK ALL THAT APPLY)

SOCIAL HISTORY (PLEASE CHECK ALL THAT APPLY)