New Patient Information:

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Lydia Wilcox
5 years ago
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1 New Patient Information: Patient Name: Date of Birth: / / Age: SEX: Male or Female SS# / / Home Address: City/State: ZIP: Home # Cell # Address Occupation: Work # Primary Language: Ethnicity: Guarantor Name : Date of Birth: Method of Contact Preferred (Circle All That Apply)*: Home Phone Cell Phone *Text and Data rates may apply - used for our purposes only Primary Care Physician Name: Last PCP visit Phone # Pharmacy Name: Location: Pharmacy # Insurance Information: Primary Insurance Name: ID# GRP# Secondary Insurance Name: ID# GRP # Who referred you to our office or how did you hear about us: Dr. Mickey D. Stapp Dr. Brian Bennett Dr. Christopher Anna Dr. Trevor S. Payne

2 Reason for your visit today: Shoe Size: Weight Height Social History: Tobacco Use ( ) Never ( ) Former ( ) Occasionally ( ) Daily packs/day Alcohol Use ( ) Never ( ) Occasionally ( ) Daily drinks/day Patient History: Allergies: Medication Allergies: Other: Please List ALL MEDICATIONS you are Currently taking (including prescribed, over-the-counter and herbal/nutritional supplements ) or PLEASE PROVIDE A LIST Name: Dose Frequency Do you have or have you ever had any of the following? Please ALL that applies ( )Acid Reflux ( )High Blood Pressure ( )Fibromyalgia ( )Arthritis ( )Asthma ( )High Cholesterol ( )Abnormal Bleeding ( )Back Trouble ( )Cancer ( )Rheumatic fever ( )Pneumonia ()Blurred/Double Vision ( )Diabetes ( )Seizures ( )Bladder Infection ( )Anemia ( )Gout ( )Stomach Ulcers ( )Chest pain/angina ( )Blood Clots ( )Heart Attack ( )Stroke ( )Mitral valve Prolapse ( )Gallbladder Disease ( )Heart Disease( )Thyroid Disease ( )Kidney Disease ( )Vein Disease ( )Hepatitis ( )Tuberculosis ( )Colon Disease ( )Leg Cramps ( )HIV/AIDS ( ) Liver Disease ( )Difficulty Breathing Please List any other Health Conditions: Please List All Prior Surgeries: Date / / Signature Dr. Mickey D. Stapp Dr. Brian Bennett Dr. Christopher Anna Dr. Trevor S. Payne

4 Privacy Practices Appointment Reminders As a service to our patients, we contact via your preferred method to remind you of your upcoming appointment. We do not discuss nor release any other information except that you have an appointment in our office at a certain day/time. (Please Circle) A. May we contact you to remind you of your appointment? YES No B. If there is no answer at your preferred number, may we leave a voic ? YES No C. If you are not available, may we leave this message with the person that answers? YES No Discussion of your Protected Health Information By law, we are not allowed to discuss your protected health information with anyone else. Is there anyone with whom we may discuss your protected health information? (Please Circle) A. NO You may only discuss my protected information with me (patient). B. YES You may discuss my protected health information with the following people only: I. Spouse II. Other Acknowledgement of Receipt of Privacy Practices I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (have had the opportunity to read/or have had read to me) and understand the Notice. I understand that I can rescind or revise my privacy choices at any time. Patient Name (Please Print) Date Signature Signature of Parent or Guardian Dr. Mickey D. Stapp Dr. Brian Bennett Dr. Christopher Anna Dr. Trevor S. Payne

HIPAA Consent Form. Conduct normal healthcare operations such as quality assessments and physician certifications.

HIPAA Consent Form. Conduct normal healthcare operations such as quality assessments and physician certifications. HIPAA Consent Form I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand