From: [re_Patients-Email-Address] To: swifc@family-dr.com Subject: Patient info [< ifcond(('[C1]' == 'Yes'),('updated'),(''))>] : [r_Patient-First-Name] [MI]. [r_Patient-Last-Name] [%DATE_GMT]
 

PATIENT INFORMATION

New Patient   [C2]        Current Patient [C1]  Please update my current information                        

First Name: [r_Patient-First-Name] MI: [MI]   Last Name: [r_Patient-Last-Name]

Address: [r_Patient-Address]

Suite/Apt # [Patient-Suite-or-AptNumber]

City: [r_Patient-City]                       State: [r_Patient-State]                 Zip Code: [Patient-Zip]  

Birthday: [r_dobmonth] / [d_dobday] / [d_dobyear]            SSN: [r_Patient-SS1]

Home Phone Number:  [r_Patient-Phone3]

Cell  Phone Number:   [Patient-Phone32]

Work Number:  [Patient-Work-Phone]

E-Mail Address: [re_Patients-Email-Address]


Marital Status: [Marital-Status]

Spouse's Name: [Spouse-name]

Do you have children? [Children]           How many? [Number-Children]

Referred by: [Referred]

Employer: [Employer]

Occupation: [Occupation]

Preferred Pharmacy:    [Preferred-Pharmacy] 

 

REASON FOR VISIT



Describe the reason for your visit:

[Describe-Pain]

HEALTH HISTORY


What medications do you take: (List medications, dose, frequency)

[Medication-You-Take]

Do you now have or have you ever had any of the following:

[m_Sympthoms]

List Past Medical History, Surgery, Hospitalizations:

[Additional-treatment]

 

EMERGENCY CONTACT

 

Contact: [Emergency-contact]

Relationship to you: [Emergency-relation]

Home phone # [Emergency-phone1]                     Work phone #: [Emergency-phone2]

 

ACCOUNT INFORMATION

Same as above:   [C2]

First Name: [r_Billing-First-Name]  MI: [Billing-MI]  Last Name:  [r_Billing-Last-Name]  Sex:  [sex]

Address:   [Resp_address]              City:  [Resp_city]  State:         [Resp_state]

Birthday:  [Resp_month] / [Resp_day] / [Resp_year]

Health Insurance Name:  [r_Health-Ins-Name]                * Other Insurance:  [OtherIns]

Insurance ID #:  [r_Insurance-ID]          Group #:  [groupID]              SSN: [r_Billing-SS1]

Relationship to you: [r_Billing-relation]           Co-pay amount:  [copay]

Insurance Billing address:  [Billing-Address] 

PO Box:  [r_PO-Box]

City:  [r_Billing-City]     State:  [r_Billing-State]     Zip Code:  [r_Billing-ZipCode]    

Phone Number:   [Billing-Phone2b]  

 

Payment method: [payment]

Credit Card Type: [Credit-Card-Type]

Credit Card Number: [Credit-number]

Exp. date: [Credit-expire]

 

I understand that all charges (including those not paid by insurance), collection fee, bank/returned check fees, legal fees and failure to keep appointment fees are the financial responsibility of the patient (or the parent/guardian in the case of a minor). I hereby authorize Dr. Schweinshaupt to release all information concerning my illness (es) and treatments to my insurance carriers/health plans. In the event that Dr. Schweinshaupt participates with my insurance carrier/health plan, I hereby assign all available benefits and payments directly to him for medical services rendered. I understand that I am financially responsible for all balances not covered by my insurance carrier/health plan, and authorize Dr. Schweinshaupt to charge my credit card for the full amount of any unpaid balances.  I acknowledge notification of the privacy practice act.