New Patient Registration

New Patient Registration Form for Dhvanit Vijapura M.D.

PLEASE DO NOT COMPLETE UNLESS YOU HAVE A CONFIRMED APPOINTMENT.
Patient Info:
Name*

First NameLast Name
Preferred Name

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Social Security #:*
Address*

Address

Street Address Line 2

City/StateState / Province

Zip
Cell Phone:*
Alternative Phone:
Email Address:*
example@example.com
Emergency Contact Name (Spouse/Guardian):
Emergency Contact Relationship:
Emergency Contact Phone Number:

Area CodePhone Number
Insurance Information
If a new patient is using insurance to visit this doctor, the patient is required to provide a copy of all the patient's insurance card(s), at least 24 hours (1 business day) before scheduled appointment, so that this information can be verified.
Primary Medical Insurance:
Name of Insured:

First NameLast Name
Date of Birth:

MonthDayYear
Date
ID #:
Group #:
Optional: Attach Picture of Card

Browse Files

Cancelof
Secondary Insurance:
Name of Insured:

First NameLast Name
Date of Birth:

MonthDayYear
Date
ID #:
Group #:
Optional: Attach Picture of Card

Browse Files

Cancelof
Pharmacy Preference (Be Specific):
Name:
Phone:
Location:
Cross streets/City/State
I certify that the information on this sheet is correct, and hereby authorize D.K. Vijapura, M.D. and his staff to provide therapy or other medical services deemed necessary for the above-named patient. I authorize the release of medical information required to collect insurance from third-party payers. The charges to the third-party payers will be a full fee. If, for any reason, insurance or payment from third-party payers does not fulfill my full financial obligation, I understand that the remainder of the charges are my responsibility to pay.
Provide an electronic signature with your mouse or with a finger on a touchscreen:*

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Date:

MonthDayYear
Patient Authorization

Please list family members or other persons, if any, whom we may contact or inform of your general psychiatric condition. These authorized persons would also have verbal access to your diagnosis, medications, and any other treatment information, including payment and health care operations, if need be:

	Name	Relationship	Phone
1
2

Other than your home address, please list an alternate address, if any, you would like billing statements or correspondence from our office to be sent:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list the preferred telephone number you wish to receive calls regarding appointments, medications, or other health care information (Please be aware that a cell phone is not a secure or private line):

Area CodePhone Number
May we leave a confidential message on your answering machine, voice mail, or with a family member?
Provide an electronic signature with your mouse or with a finger on a touchscreen:*

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Date:

MonthDayYear

Principles of Medical Practice
I, as a medical professional, subscribe to a body of ethical standards primarily for the benefit of my patients. I recognize my responsibility not only to my patients but to society, to other health care professionals, and to myself. The following is my standard of conduct which defines the essentials of honorable behavior for a physician.

A physician must be dedicated to providing competent medical services with compassion and respect for human dignity.

A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud and deception. Sexual harassment of patients or staff, or sexual activity between medical staff and other staff members, or with patient or patient family members is unethical, and will not be tolerated and should be reported immediately to the practice manager.

A physician shall respect the laws and also recognize a responsibility to seek changes in those requirements that are contrary to the best interest of their patient.

A physician shall respect the rights of patients, colleagues, and of other health care professionals, and shall safeguard patient confidences within the constraints of the law. As a Psychiatrist, I will never conduct a physical examination.

A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues and the public, and obtain consultation and the use of the talents of the other health professionals when indicated.

A physician shall, in the provision of appropriate patient care, except in emergency, be free to choose whom to serve, with whom to associate and choose the environment in which to provide medical services.

A physician shall recognize their responsibility to participate in activities contributing to an improved community.
Provide an electronic signature with your mouse or with a finger on a touchscreen:*

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I have read and understand the above principals as it relates to my treatment with D.K. Vijapura, M.D.

Phone Appointment Reminders
Our practice uses an Electronic Medical Records program that will allow us to send text messages and emails to your phone as reminders for appointments.

If you would like to receive text notifications and emails for appointments, expressed written consent is needed to do so. This consent can be revoked at any time the patient wishes, at which time no further text messages will be sent.

By providing my signature below, I give consent to receive text or email messages/notifications from Dr. Vijapura's office as a reminder of appointments scheduled.
Text Consent Decision:*

I choose to opt in of text reminders.I choose to opt out of text reminders.
Email Consent Decision:*

I choose to opt in of email reminders.I choose to opt out of email reminders.
Phone Number for notifications to be sent to:

Area CodePhone Number
Email for notifications to be sent to:
example@example.com
Provide an electronic signature with your mouse or with a finger on a touchscreen:*

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	Enter Number
Days
Months
Years

No Call/No Show Policy Agreement
It is vital that you arrive at your schedule appointments on time. Due to the increasing issue of patients failing to appear for their scheduled appointments, there is a fee for No Call/No Show. You must call 24 hours PRIOR to your appointment (and speak to someone or leave a message!) to cancel or reschedule. If you do not call or come to your appointed time slot, you will be charged $40, to be paid in full at your next appointment, NO EXCEPTIONS. Multiple No Call/No Shows may result in an increase in this fee or a refusal to treat you further.

I have read and do understand this new policy. I agree to pay the fee if I fail to comply.
Provide an electronic signature with your mouse or with a finger on a touchscreen:*

Clear

Sentence Completion Test

Complete these sentences to express your feelings. Try to do every one. Be sure to make a complete sentence. *

	Finish Sentence Here
I wish
My Happiest moment
My Mother
Here
My Home
I
Please
Women
During my childhood
My Life
You
While falling asleep
Death
I dream
My father
I fear
Men
My body
People
Work
My thoughts
God
My Family
I'd like

I, {name}, certify that the information is filled out to the best of my knowledge. By selecting submit, D.K. Vijapura, M.D. and his staff will receive these responses in a HIPAA compliant secured format.
Should be Empty:

	Yes	No
Have you ever seen a psychiatrist?
Do you take medications?
Have you ever been hospitalized?
Are you allergic to any medications?
Have you ever seen a counselor?

	Self	Family	N/A	If Yes, Please Explain
Birth Defect
Bleeding Disorder
Blindness/Eye Abnormality
Diabetes
Down Syndrome
Alzheimer's
Cancer
Heart Disease
Kidney Disease
Mental Retardation
Neurological Disorder
Psychiatric Disorder
Respiratory Disorder
Seizures/Epilepsy
Thyroid Disease
High Blood Pressure

	Active	Please Explain for how long and severity
Diarrhea/Constipation
Shortness of Breath
Muscle Stiffness
Swollen Glands
Asthma
Intolerance to Hot or Cold
High Blood Pressure
Allergies
Diabetes
Neurological Disorders
Pain Syndrome
Discharge from Ears, Nose, or Mouth
Loss of Function to Hands/Feet
Difficulty Walking
Other

	Never	Rarely	Sometimes	Often	Very Often
How often do you make careless mistakes when you have to work on a boring or difficult project?
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
How often do you have problems remembering appointments or obligations?
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing when you have time to yourself?
How often do you feel overly active and compelled to do things, like you were driven by a motor?
How often do you find yourself talking too much when you are in a social situation?
When you're in a conversation, how often do you find yourself finishing sentences of the people you are taking to, before they can finish them themselves?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?

	Yes	No
You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
You were so irritable that you shouted at people or started fights or arguments?
You felt much more self-confident than usual?
You got much less sleep than usual and found you didn't really miss it?
You were much more talkative or spoke much faster than usual?
Thoughts raced through your head or you couldn't slow your mind down?
You were so easily distracted by things around you that you had trouble concentrating or staying on track?
You had more energy than usual?
You were much more active or did many more things than usual?
You were much more social or outgoing than usual, for example you telephoned friends in the middle of the night?
You were much more interested in sex than usual?
You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
Spending money got you or your family into trouble?
If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

New Patient Registration Form for Dhvanit Vijapura M.D.

Patient Info:

Insurance Information

Pharmacy Preference (Be Specific):

Patient Authorization

Principles of Medical Practice

Phone Appointment Reminders

Chief Concern

Patient Family Health History

Personal Health

No Call/No Show Policy Agreement

Beck's Depression Inventory (BDI)

ADHD Screen

Bipolar Mood Scale

Sentence Completion Test

	Medication	Prescribing Doctor
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2
3
4
5
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7
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