Patient Intake Form - English

Intake Form – English

Patient Registration

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Patient Registration

Your Name

First Middle Last

Date of Birth

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sex:

Male

Female

Age

Please enter a number from 0 to 120.

Name of Spouse

Home Phone

Alternate Contact/Cell:

Social Security #

Employer

Occupation

Primary Care Doctor

Office Phone

Fax Number

Preferred Pharmacy

Pharmacy Address

Pharmacy Phone

Pharmay Fax

Insurance Information

SELF-PAY

(I have no insurance / my insurance is not accepted)

Primary Insurance

Whose Plan?

Self

Spouse

Parent

Subscriber Name

Subscriber Birthdate

Member ID #

Group #

Member ID #

Secondary Insurance

Whose Plan?

Self

Spouse

Parent

Secondary Subscriber Name

Secondary Subscriber Birthdate

Secondary Member ID#

Secondary Group #

In Case of Emergency, Please call:

Name

First Last

Phone

Relationship to Patient

I understand that Telemedicine requires me and my healthcare provider to communicate information interactively through video equipment, about my health, including prior health history, present symptoms, laboratory and diagnostic tests.

Details of your medical history, examinations, x-ray, and tests may be discussed with other health professionals through the use of interactive video, audio, and telecommunications technology.
Visual and physical examination of you may take place.
Nonmedical technical personnel may be requested to enter the area where telemedicine is being performed.
Video, audio, and/or photo recordings may be taken of the encounter(s).
On the benefits and risks of telemedicine (174.5.b Regulation), telemedicine allows the provision of quality services without having to travel long distances, but in turn presents some risks as described below:
- a. There is a risk, despite our best efforts to protect the privacy of patient information, that the security protocol may fail causing a violation of the privacy of personal medical information.
- b. There is a risk of a delay in diagnosis and medical treatment due to unexpected failures of electronic equipment for this service.
- c. I understand that if telemedicine consultation cannot be done, I will be referred to another health professional for a consultation or a query will be scheduled in person (174.5.c of the Regulation).
I understand that I can withdraw my consent at any time to participate in this therapeutic means and then be referred to another health professional.
Any dissemination of patient-identifiable images or information and certain necessary administrative and operational activities supporting your care shall not occur without your authorization.

By signing below, I understand the written information provided above and voluntarily and freely give my consent to take part in the telemedicine—be it via video conference, phone, or text message—with the doctor and his team for evaluation, assessment, and diagnosis for my current medical condition.

Signature

Date

Patient Acknowledgment and Consent for Use and Disclosure of Protected Health Information

Assignment of Benefits

I hereby authorize payment of benefits directly to the physician for the surgical and/or medical services herein specified. I am aware of my responsibility to pay any non-covered service, as well as any co-pay, coinsurance, and/or deductible due at the time of treatment.

Patient Signature

Date

Release of Information

Insurance: I hereby authorize the physician to release any information acquired in the course of my examination, treatment, or surgery for billing and treatment purposes only.

Patient Signature

Date

Cancellation Policy

Please understand that we request a 24-hour cancellation notice. Failure to notify us within 24 hours of a scheduled appointment will result in a $50.00 fee due on or before your next visit. Please speak to an office representative for clarification of any concerns.

Patient Signature

Date

Telemedicine Consent

Details of your medical history, examinations, x-ray, and tests may be discussed with other health professionals through the use of interactive video, audio, and telecommunications technology.
Visual and physical examination of you may take place.
Nonmedical technical personnel may be requested to enter the area where telemedicine is being performed.
Video, audio, and/or photo recordings may be taken of the encounter(s).
On the benefits and risks of telemedicine (174.5.b Regulation), telemedicine allows the provision of quality services without having to travel long distances, but in turn presents some risks as described below:
- a. There is a risk, despite our best efforts to protect the privacy of patient information, that the security protocol may fail causing a violation of the privacy of personal medical information.
- b. There is a risk of a delay in diagnosis and medical treatment due to unexpected failures of electronic equipment for this service.
- c. I understand that if telemedicine consultation cannot be done, I will be referred to another health professional for a consultation or a query will be scheduled in person (174.5.c of the Regulation).
I understand that I can withdraw my consent at any time to participate in this therapeutic means and then be referred to another health professional.
Any dissemination of patient-identifiable images or information and certain necessary administrative and operational activities supporting your care shall not occur without your authorization.

Patient Name

Date

Patient Signature

Date

Patient Intake Form – English

Intake Form – English

Patient Registration

Insurance Information

In Case of Emergency, Please call:

Patient's Medical History

Males Only

Females Only

Please check if you have now or have had in the past any of the following:

Patient Acknowledgment and Consent for Use and Disclosure of Protected Health Information

Assignment of Benefits

Release of Information

Cancellation Policy

Release of Information

Sexual Health Inventory for Men (SHIM)

PATIENT INSTRUCTIONS

Telemedicine Consent

Intake Form – English

Patient Registration

Insurance Information

In Case of Emergency, Please call:

Patient's Medical History

***Males Only***

***Females Only***

Please check if you have now or have had in the past any of the following:

Patient Acknowledgment and Consent for Use and Disclosure of Protected Health Information

Assignment of Benefits

Release of Information

Cancellation Policy

Release of Information

Sexual Health Inventory for Men (SHIM)

PATIENT INSTRUCTIONS

Telemedicine Consent

Males Only

Females Only