New Patient Registration Form

New Patient Registration

Please fill in the form below
IMPORTANT
PLEASE READ BEFORE YOU COMPLETE THIS FORM

Thank you for allowing the Faith Healthcare Services (FHCS) staff to serve you. We appreciate your trust in our care and look forward to serving you. Our Business is YOU. To serve you better, please understand that we work on a schedule. Be prepared before arrival to notify us of:

1. Any changes in patient’s condition since our last visit

2. If the patient is taking any new medications or allergies

3. If the patient has followed up with other doctors since our last visit

4. Provide all current medications and MAR (if available) for review.

DON’T ASK STAFF to write prescriptions, referrals or excuse letters for you, your family members or friends. This is illegal.

NEW PATIENTS: Cannot be evaluated with incomplete admission forms. These forms must be signed in blue or black ink. Information must be legible.

Please have all medications and pharmacy MAR available for review.

NARCOTICS: We do not prescribe Schedule II drugs such as Morphine, Methadone, Fentanyl, Oxycodone, Percocet, Lortab. Neither do we write Xanax, Ambien, Klonopin, Restoril.

We are more than willing to refer you to pain management.

We are committed to serving you in a timely manner with your chronic stable conditions. If your illness is acute, we will attempt to see you that week, however, we do not make emergency calls. If we cannot serve you to the best of our capabilities, we will do our best to help you find another provider.

Thank you.

Faith Healthcare Services, Inc.
Name

FirstLast
Date of Birth

MonthDayYear
Social Security Number
Age
Weight
Height
Sex
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PenicilinCodineSulfaOther
Check box only of you have an illness
AnemiaAppetite - Loss ofArthritis or goutAsthmaBack PainIncontinenceCholesterol/hyperlipidemiaDiabetes mellitusCOPDConfusion/ memory lossGlasses or contact lensGlaucoma or cataractsPoor circulationHearing loss or ringingHeartburn/GERDHigh blood pressureKidney problemConstipationProstate problemsLiver disease or hepatitisShortness of breathHeart diseaseSleeping problems/insomniaStrokeSwelling feet, ankles, handsThyroid diseaseNervousnessSnoreDepressionSeizures
YesNo
If yes, please list it here
Pharmacy Name
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number

Area CodePhone Number
Pharmacy Fax Number

Area CodePhone Number
Insurance Information
Medicare number
Medicaid number
Other Insurance
Insurance group number
Insurance Phone Number

Area CodePhone Number
Physician’s name
Physician's Phone Number

Area CodePhone Number
Physician's Fax Number

Area CodePhone Number
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is responsible party for your billing/Emergency Contact
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Job (former if retired)
SingleMarriedDivorcedWidowed
Smoke
If yes, what type?
How many packs a day?
Alcohol
If yes, what type?
How drinks a week/ day?
Surgery: type, year, & hospital
1. Diabetes2. Hypertension3. Cancer4. Stroke5. Heart trouble6. Arthritis7. SeizuresOther
Who in the family with disease (Put number thatcorresponds to disease beside the name) eg 1 (diabetes) mother
Wellness/Prevention
Colonoscopy date

MonthDayYear
TB/PPD date

MonthDayYear
Flu vaccine

MonthDayYear
Pneumonia vaccine date

MonthDayYear
Tetanus date

MonthDayYear
YesNo
FEMALE ONLY
Date of last Pap smear

MonthDayYear
Mammogram

MonthDayYear
Date of last period

MonthDayYear
MALE ONLY
PSA

MonthDayYear
MEDICAL RECORD RELEASE AUTHORIZATION
Patient Name

First NameLast Name
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
RELEASE MEDICAL INFORMATION TO:
Faith Healthcare Services, Inc 3725 Zoar Rd. Snellville, GA 30039
Phone: 770-248-1637 Fax: 770-248-1638
Information to be released: (check all that apply)
Face SheetHistory & Physical examDischarge summaryFamily/Social HistoryX-ray, Imaging ReportsLaboratory ResultsConsultationsEntire record
From

MonthDayYear
To

MonthDayYear
Further medical care, reportChanging PhysiciansPersonalLegal Investigation
Assignment of Benefits (payment)
MEDICARE PATIENT ONLY Medicare Beneficiary Lifetime Payment Authorization
Medicare Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Should be Empty: