PatientPatient Information Form • July 11th, 2022
INTERNAL MEDICINE GROUP OF TAMPA BAYPatient Information Form • July 23rd, 2018
Today’s date ________________Patient Information Form • March 13th, 2018
Dental Insurance Company (If you have a secondary insurance, please provide that information together with your primary dental insurance so that we can give you the best estimate possible)
Spring Creek Dental Associates, LLCPatient Information Form • June 7th, 2017
_____ (Please Initial) I authorize the use of my mobile phone number (listed above) to receive scheduling and billing messages. I agree to update this office if my mobile number changes.
For Office Use Only ____ HF ____LabCorp ____NPL ____ TW ____iCPatient Information Form • November 1st, 2016
PATIENT INFORMATIONPatient Information Form • May 12th, 2014
Single Married Widowed Separated Divorced Birthdate _______ _ _ __ SS# ____ _ Relationship to Patient ______ _ _ _ _Patient Information Form • December 18th, 2017
BURBA DENTAL PARTNERS Advanced Cosmetic DentistryPatient Information Form • September 9th, 2024
___Heart murmur ___Mitral valve prolapses ___Artificial heart valves ___Rheumatic fever ___Cardiovascular disease ___Angina ___Arteriosclerosis ___Congestive heart failure ___Coronary artery disease ___Damaged heart valves ___Heart attack ___Low blood pressure ___High blood pressure ___Congenital heart defects ___Pacemaker ___Rheumatic heart disease ___Abnormal bleeding ___Diabetes Type I/Type II ___Eating disorder ___Joint replacement ___Anemia ___Blood transfusion If yes, date: ______________ ___Hemophilia ___HIV/AIDS ___Arthritis ___Autoimmune disease ___Rheumatoid arthritis ___Systemic lupus erythematosus ___Asthma ___Bronchitis ___Emphysema ___Sinus trouble ___Tuberculosis ___Cancer/Chemo/Radiation ___Chest pain upon exertion ___Chronic pain ___Malnutrition ___Gastrointestinal disease ___G. E Reflux/Heartburn ___Ulcers ___Thyroid problems ___Stroke ___Glaucoma ___Hepatitis, jaundice, liver disease ___Epilepsy ___Fainting spells/seizures ___Neurological disorders ___Sleep disor
FIRST NAME MIDDLE LASTPatient Information Form • October 27th, 2020
CONTACT PHONE RELATIONSHIP INJURY AREA ONSET DATE IS THIS CONDITION THE RESULT OF AN AUTO ACCIDENT? YES NO DATE AUTO INSURANCE PIP ADJUSTER PHONE FAX EMAIL AUTHORIZATION OTHER ACCIDENT? YES NO DATE ATTORNEY PHONE FAX EMAIL INSURANCE COMPANY PHONE AGENT PHONE EMAIL GUARANTOR HOW DID YOU HEAR OF SPINE & SPORT INSTITUTE?
FIRST NAME MIDDLE LAST ADDRESS CITY STATE ZIPPatient Information Form • October 27th, 2020
CONTACT PHONE RELATIONSHIP OCCUPATION EMPLOYER IF RETIRED, PREVIOUS OCCUPATION INJURY AREA DATE OF INJURY COMMECIAL INSURANCE
Patient’s Name ________________________________________________________________ _________________________ Last First Middle Address ___________________________ _______________________________________________________________________ Street & Apt # City...Patient Information Form • April 26th, 2022
The adult accompanying a minor and the parents (or guardian) of the minor are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized with a credit card, check, or cash payment at the time of service. As guardian of the minor I authorize treatment unless otherwise noted in writing.
CONSENT TO COMMUNICATEPatient Information Form • November 2nd, 2017
Method Ok to Leave Voicemail Ok to Leave Message with Another Person Preferred Contact Method(s) Call Work Phone Yes No Yes No Call Cell Phone Yes No Yes No Call Home Phone Yes No Yes No Send Email - - Would you like to receive our specials via email? - -
CARLTON CARDIOLOGY ASSOCIATES, INC. Gregory T. Smith, M.D. Suad A. Ismail, M.D.Patient Information Form • March 20th, 2015
PLEASE SIGN IF YOU AGREE TO AUTHORIZE CARLTON CARDIOLOGY ASSOCIATES, INC. TO COMMUNICATE PERSONAL MEDICAL INFORMATION TO THE ABOVE-NAMED NEXT OF KIN.
IFPain AssociatesPatient Information Form • January 22nd, 2023
For and in consideration of services rendered, I agree to make payment to IFPain Associates when billed for any and all charges not covered by valid insurance benefits. I authorize payment directly to IFPain Associates for health insurance benefits payable to me under terms of my policy but not to exceed the balance due for services performed during this period of treatment. IFPain Associates may seek, release and verify all or part of my medical and/or financial records to any person, corporation or government agency which is or may be liable under a statute, regulation or contract to IFPain Associates, myself, a family member or my employer for all or part of the IFPain Associates charge.
