Work Phone Number h How did you find us? Choose One... Website address Applying for a property located at h APPLICANT INFORMATION IDENTIFICATION Social Security Number s Date of Birth s PHOTO IDENTIFICATION* Provide one of the following: Driver's License Driver's License # s State
Work Phone Number. Fax Number E-Mail Address
Work Phone Number. This is a draft facility use agreement. It may need modification to meet unique needs and circumstances. Xxxxxx Insurance Services, Inc. makes no warranty as such. This template agreement is a guide only. Facility use agreements should be reviewed by legal counsel prior to execution.
Work Phone Number. Medication List Name of Medication Dosage How many times a day Information Assignment of Benefits and Financial Agreement: I hereby give lifetime authorization for payment of insurance benefits to be made directly to Living Water's Medical Clinic, Inc. and an assisting physician, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney's fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original. *Signature: *Date: By typing your name and clicking the "submit" button on the bottom of the last page, you are electronically signing the record. Method of Payment: Cash Credit Card (Only Visa, Mastercard, or Discovery) Check The * sign indicates REQUIRED FIELDS. We cannot serve you without completed information on required fields. Adult Health History Name/Nombre Age/Edad D.O.B./Cuando Nacio Date/Fecha History of Past Illness Measles/Serampion No Yes/Si Rheumatic Fever/Fiebre Reumatica No Yes/Si Mumps/Paperas No Yes/Si Heart Disease/Enfermedad del Corazon No Yes/Si Chickenpox/Viruela No Yes/Si Tuberculosis No Yes/Si Diabetes No Yes/Si Venereal Disease/Enfermedad Veneria No Yes/Si Stroke/Embolio No Yes/Si Serious Disease/Enfermedad Xxxxxx No Yes/Si Ever hospitalized/Has sido hospitalizado No Yes/Si Explain/Explicacion ………………………………………………………....... Ever had surgery/Ha tenido operaciones No Yes/Si Explain/Explicacion …………………………………………………………… Had broken bones/Ha tenido fracturas No Yes/Si Explain/Explicacion …………………………………………………………... Head concussions or injuries/ Glopes o heridas de cabeza No Yes/Si Explain/Explicacion …………………………………………………………... Date of last Tetanus/La fecha de su ultima inmunizacion de Tetano ……………….………………………….……….………………………… Date of last PapSmear/La fecha de papanicolou de cancer ……………….………………………….……….……………............................... Date of last Mammogram/Mammographia ……………….………………………….…………………………….…………………………………. Family History/Histori Familiar: Has anyone in your family ever had?/Ha habido en su familia? Cancer Diabetes Tuberculosis Heart trouble/Enfermedad del Corazon High blood pressure/Presion alta Stroke/Embolio Convulsions/Epilepcia Suicide/Suicidio Social History/Historia Social No Yes/Si Who/Quien? ……………….………………………….… No Yes/Si Who/Q...
Work Phone Number t How did you find us? Choose One... Website address t Applying for a property located at t APPLICANT INFORMATION IDENTIFICATION Social Security Number t Date of Birth t PHOTO IDENTIFICATION* Provide one of the following: Driver's License Driver's License # t State
