New Patient Registration Form
| Dr. Martin Blackwell |
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Today's date:___________ Primary Physician: ___________________
Patients Last Name: First Name: Middle: Maritial status
__________________ ___________________ __________ M S W D
Street Address: _______________________ City:________________________
State: ___________ zipcode ______________ Cell Phone #______________
Home # ________________ Work # _______________________ Ext. ______
Patients Social Security # _______________________ Date of Birth__________
Emergency contact person: __________________________________
Relationship to patient? _____________________________________
Phone #______________________________________
INSURANCE INFORMATION
Name of insurance co _______________________________ Group#_________
Policy #__________________________ Subscribers date of birth___________
Subscribers Name___________________________ Work # ________________
Subscribers SS#_____________________________
Subscribers employer___________________________________ Address if
different than yours ____________________________________________
Secondary Insurance Co: ________________________ Policy # _____________
Who is subscriber for this plan? _______________________________________
PERSONAL MEDICAL HISTORY
Allergies to medications _____________________________________________
Do you have a history of any of the following:
Diabetes Yes NO Kidney Disease Yes NO
Tuberculosis Yes NO Ulcer Yes NO
Rheumatic Fever Yes NO Epilepsy Yes NO
Joint Replacement Yes NO Joint Pain Yes NO
Dizziness Yes NO Liver Disease Yes NO
List all hospital admissions: __________________________________________
Have you ever had Hepatitis? Yes NO Type? _____________________
Have you ever had any form of cancer: Yes No Type? ________________
Have you ever had chemotherapy/radiation treatments? Yes No
Have you ever had any previous skin diseases? Yes No What kind? ________
Any personal or family history of Malignant Melanoma? Yes No Who? _______
Have you ever fainted during any medical procedures? Yes No
Please list all current illnesses/medical conditions_________________________
________________________________________________________________
Please list all medications you are taking(oral, external, topical,creams, lotions,
birth control, vitamins, herbs etc. ___________________________________
PRIVACY CONSENT - DO WE HAVE PERMISSION TO:
(Please answer all of the following questions)
Can we leave a message on your answering machine? Yes No
Can we leave a message at your place of employment? Yes No N/A\
Do we have permission to send/receive medical information to/from
consulting physicians? Yes No
Can we discuss medical conditions with any member of your family? Yes NO
If yes, whom? ________________________
This notice is effective May 11, 2006 and any alterations or amendments made
hereto will expire seven years after which the record was created. My signature
below acknowledges that I have been offered and/or received a copy of The
Notice.
Patients Name(print)______________________Date ______________
Signature____________________________________
If patient is a minor, or being represented by another party:
Parent/Guardian name(print) _____________________ Date______________
Signature __________________________________
MANAGED CARE/PPO/HMO OR MEDICARE PATIENTS
I assume responsiblity for any service that is not approved on my referral(if such
form is required by my plan); any service which is cosmetic in nature and/or not
covered by my insurer; any visit for which I have not presented a valid referral on
the day of service or is not ultimately covered by my insurer. I assign payment
benefits for my primary, secondary and/or medigap plan to this provider. Any
deductible, copayment or coinsurance designated by my plan is my responsibility.
I do hereby agree to pay Dr. Martin Blackwell the amount of any and all bills for
services rendered to the above named patient not covered by my insurance into
which the physisin has entered into an agreement. I hereby authorize the release
of information necessary to file a claim with my insurer, and/or which case to any
insurance company involved in my care. A copy of this signature is as valid as the
original.
X________________________________________________ _________
Signature of patient/patients parent or guardian required Date
Patients Last Name: First Name: Middle: Maritial status
__________________ ___________________ __________ M S W D
Street Address: _______________________ City:________________________
State: ___________ zipcode ______________ Cell Phone #______________
Home # ________________ Work # _______________________ Ext. ______
Patients Social Security # _______________________ Date of Birth__________
Emergency contact person: __________________________________
Relationship to patient? _____________________________________
Phone #______________________________________
INSURANCE INFORMATION
Name of insurance co _______________________________ Group#_________
Policy #__________________________ Subscribers date of birth___________
Subscribers Name___________________________ Work # ________________
Subscribers SS#_____________________________
Subscribers employer___________________________________ Address if
different than yours ____________________________________________
Secondary Insurance Co: ________________________ Policy # _____________
Who is subscriber for this plan? _______________________________________
PERSONAL MEDICAL HISTORY
Allergies to medications _____________________________________________
Do you have a history of any of the following:
Diabetes Yes NO Kidney Disease Yes NO
Tuberculosis Yes NO Ulcer Yes NO
Rheumatic Fever Yes NO Epilepsy Yes NO
Joint Replacement Yes NO Joint Pain Yes NO
Dizziness Yes NO Liver Disease Yes NO
List all hospital admissions: __________________________________________
Have you ever had Hepatitis? Yes NO Type? _____________________
Have you ever had any form of cancer: Yes No Type? ________________
Have you ever had chemotherapy/radiation treatments? Yes No
Have you ever had any previous skin diseases? Yes No What kind? ________
Any personal or family history of Malignant Melanoma? Yes No Who? _______
Have you ever fainted during any medical procedures? Yes No
Please list all current illnesses/medical conditions_________________________
________________________________________________________________
Please list all medications you are taking(oral, external, topical,creams, lotions,
birth control, vitamins, herbs etc. ___________________________________
PRIVACY CONSENT - DO WE HAVE PERMISSION TO:
(Please answer all of the following questions)
Can we leave a message on your answering machine? Yes No
Can we leave a message at your place of employment? Yes No N/A\
Do we have permission to send/receive medical information to/from
consulting physicians? Yes No
Can we discuss medical conditions with any member of your family? Yes NO
If yes, whom? ________________________
This notice is effective May 11, 2006 and any alterations or amendments made
hereto will expire seven years after which the record was created. My signature
below acknowledges that I have been offered and/or received a copy of The
Notice.
Patients Name(print)______________________Date ______________
Signature____________________________________
If patient is a minor, or being represented by another party:
Parent/Guardian name(print) _____________________ Date______________
Signature __________________________________
MANAGED CARE/PPO/HMO OR MEDICARE PATIENTS
I assume responsiblity for any service that is not approved on my referral(if such
form is required by my plan); any service which is cosmetic in nature and/or not
covered by my insurer; any visit for which I have not presented a valid referral on
the day of service or is not ultimately covered by my insurer. I assign payment
benefits for my primary, secondary and/or medigap plan to this provider. Any
deductible, copayment or coinsurance designated by my plan is my responsibility.
I do hereby agree to pay Dr. Martin Blackwell the amount of any and all bills for
services rendered to the above named patient not covered by my insurance into
which the physisin has entered into an agreement. I hereby authorize the release
of information necessary to file a claim with my insurer, and/or which case to any
insurance company involved in my care. A copy of this signature is as valid as the
original.
X________________________________________________ _________
Signature of patient/patients parent or guardian required Date