New Patient Paperwork

New Patient Paperwork [PDF]


Thomas V. Ripp, M.D.    Camille A. Graham, M.D.    Neil M. Vora, M.D.     Wha-Joon Lee, M.D.    
______________________________________________________________________________
Patient Information
Name (Last)______________________(First)____________________DOB____/____/____(Age)____
Social Security #______________________________     TDL# ________________________________
Marital Status:  S   M   D   W  Sex:  M   F       Race: __________________ Ethnicity:______________
Address(Street)________________________________ (City)____________(St)______(Zip)________
Phone(Home)_________________________________ (Cell)_________________________________
Employer:____________________________________ Wk Phone:_____________________________
Parent/Guardian Information (if patient is under 18)

Name (Last)_________________________(First)_______________________DOB_____/_____/_____
Relationship to Patient:____________________________________________
Social Security #______________________________     TDL# ________________________________
Marital Status:  S   M   D   W     Sex:  M   F 
Address(Street)________________________________ (City)____________(St)______(Zip)________
Phone(Home)_________________________________ (Cell)_________________________________
Employer:____________________________________ Wk Phone:_____________________________
Spouse Information

Name (Last)_________________________(First)_______________________DOB_____/_____/_____
Social Security #______________________________     TDL# ________________________________
Marital Status:  S   M   D   W     Sex:  M   F 
Address(Street)________________________________ (City)____________(St)______(Zip)________
Phone(Home)_________________________________ (Cell)_________________________________
Employer:____________________________________ Wk Phone:_____________________________
Insurance Information

Primary Insurance:_____________________Insurance Phone#_________________________________
Insured Name: ________________________DOB: ___________Relationship to Patient_____________
Insured ID#__________________________Group#___________________Employer_______________

Secondary Insurance: __________________ Insurance Phone#_________________________________
Insured Name: _______________________DOB: ____________Relationship to Patient_____________
Insured ID#__________________________Group#_________________Employer_________________
Emergency Contact               (NOT LIVING WITH YOU)

Name (Last)_______________(First)______________ Relation to Patient _____________DOB ______
Phone(Home)__________________(Work)____________________(Cell)________________________

Were you referred to us by another physician? ___ If yes Dr. (name) ____________________________
Name of your Primary Care Doctor:   _____________________________________________________
Preferred Pharmacy  Name & Number:    __________________________________________________
What number can we contact you at? ______________________________Can we leave a message?___
Family Members we can release information to: _____________________________________________
                                                                              ____________________________________________
                                                                        (Name)                                 (Relationship)
Authorization to Treat, Authorization to Release Information & Assignment of Benefits:
I authorize the physician(s) of  Allergy ENT to treat me.  I authorize any physician/agent of Allergy ENT to release my medical records or medical information to any physician, hospital or other medical provider or supplier who may participate in my medical care.  I authorize any physician, hospital, or other supplier to release my medical records and information to the physician(s) of Allergy ENT.  I authorize any physician/agent of  Allergy ENT to release my medical records and/or information to my insurance carrier to determine my benefits.  I authorize my insurance carrier(s) to pay my medical benefits directly to the physician(s) of Allergy ENT.  I understand that I am financially responsible for all charges not paid by the insurance carrier(s).  I agree that a photocopy of this agreement will be considered the same as the original.
___________________________________________________    Date:__________________
Patient Signature (Parent or Guardian, if patient is a minor)  New Patient Demographics  04/19/12 tjd

                    

 

                            ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.


___________________________________________________________________________
Please print your name here     Date of Birth


____________________________________________________________________________
Signature       Date


                     ACKNOWLEDGEMENT OF FINANCIAL POLICY


  I have read, understand and agree to the Financial Policy of Allergy, Ear, Nose & Throat Clinic.

__________________________________________________________________________________________________________________
Signature of Patient or Legal Guardian                      Relationship to Patient                  Date         


                      CONSENT FOR TREATMENT OF MINOR CHILDREN
                      ACCOMPANIED BY AN ADULT OTHER THAN PARENT OR LEGAL GUARDIAN


  I,_________________________________________________, Authorize, Allergy ENT Clinic of NE TX to treat
                                (Parent or legal guardian)

  _________________________________________for routine and emergency medical treatment
                        (Child’s name and DOB)    
  when necessary by qualified medical personnel when accompanied by:

______________________________________________________________________________
                
                
               This authorization is valid for:
                   
o Today’s visit only
                        
o From _________________(date) to______________________(date)

o Until revoked in writing by me


              This consent will be valid for (1) year from the date signed unless otherwise specified in writing.
             _____________________________________________________________________________
             Printed name of parent/legal guardian             
            _____________________________________________________________________________
            Signature of parent/legal guardian                                                       Date    


                   Consent page 04/19/12 tjd

 

 

MEDICAL HISTORY QUESTIONNAIRE:  PLEASE ANSWER ALL QUESTIONS & PRINT LEGIBLY

NAME____________________________________________________   AGE_______  DATE___________________

WHY ARE YOU SEEING THE DOCTOR TODAY?  __________________________________________________________________________

PAST PERSONAL MEDICAL HISTORY (PLEASE CIRCLE):

ACID REFLUX       ASTHMA       BLOOD TRANSFUSION       CANCER       COPD       CORONARY ARTERY DISEASE       DEPRESSION       DIABETES

HEART MURMUR       HEART ATTACK       HIGH BLOOD PRESSURE       HIGH CHOLESTEROL       HUMAN IMMUNODEFICIENCY VIRUS (HIV)

KIDNEY FAILURE       LIVER DISEASE (HEPATITIS)       PROBLEMS WITH ANESTHESIA         SLEEP APNEA       STOMACH ULCER       STROKE 
  
THYROID DISORDER       VERTIGO      OTHER_____________________________________________________________________________  

MEDICATIONS?  YOU ARE CURRENTLY TAKING (INCLUDING OVER THE COUNTER OR HERBAL)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

CIRCLE IF YOU TAKE ANY OF THE FOLLOWING:             ASPIRIN/BLOOD THINNER  NASAL SPRAY  BIRTH CONTROL PILL

MEDICATION ALLERGY? NO______ YES_____ LIST______________________________________________________________

SURGERY?   NO______ YES_____LIST ______________________________________________________________

______________________________________________________________________________________________________________

FAMILY HISTORY (PLEASE CIRCLE):

ALLERGY ASTHMA  DIABETES  EAR TUBES FREE BLEEDING HEAD/NECK CANCER HEARING LOSS
HEART DISEASE HIGH BLOOD PRESSURE  PROBLEMS WITH ANESTHESIA  THYROID PROBLEMS
  
SOCIAL HISTORY?
DO YOU SMOKE OR USE CHEWING TOBACCO (CIRCLE WHICH)  NO_____ QUIT_____YEARS AGO    
        YES_____LIST PACKS_____PER DAY; FOR _____YEARS     
DO YOU DRINK ALCOHOL?   NO_____ YES______   LIST NUMBER OF DRINKS DAILY_______

OCCUPATION: __________________________________  MARITAL STATUS (PLEASE CIRCLE):  S   M   D   W

ARE YOU OR COULD YOU BE PREGNANT? NO___ YES____                              **NAME OF REFERRING DOCTOR: _________________________    

ADDITIONAL PERSONAL SYMPTOMS (PLEASE CIRCLE):
GENERAL: FATIGUE         FEVER         CHILLS         NIGHT SWEATS         WEIGHT LOSS         WEIGHT GAIN
EYES:  CHANGE IN VISION         REDNESS         DRYNESS         BURNING         WATERY/ITCHY
HEAD/NECK: HEADACHES     DENTAL PAIN       NECK STIFFNESS       EAR PAIN       DECREASED SENSE OF SMELL      SNORING       DRY MOUTH
CARDIAC: CHEST PAIN         IRREGULAR HEART BEAT         FAINTING
LUNG:      SHORTNESS OF BREATH         COUGH         HOARSENESS
GI:  NAUSEA          VOMITING          HEARTBURN         TROUBLE SWALLOWING
SKIN:  RASH         ECZEMA       HIVES         
NEUROLOGIC: TINGLING OR NUMBNESS       SEIZURE         DEVELOPMENTAL DELAY         DIZZYNESS/VERTIGO
MUSCLE/JOINT: JOINT PAIN         MUSCLE CRAMPS
ENDOCRINE: LOSS OF HAIR         CONSTIPATION         COLD INTOLERANCE         HEAT INTOLERANCE
PSYCHIATRIC:  DEPRESSION         DIFFICULTY SLEEPING
HEMATOLOGY:    EASY BRUISING        FREE BLEEDING