emergency contact (other than patient) medical antianxiety agents, sedative-hypnotics and...

Download EMERGENCY CONTACT (OTHER THAN PATIENT) MEDICAL antianxiety agents, sedative-hypnotics and antidepressants

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  • Please bring your ID and Medical/Dental Insurance cards to all appointments

    Subscriber’s Name

    Dental Insurance Group No. ID No.

    Relationship to patientRelationship to patient

    Attorney: Date of Injury:

    Auto Accident: Yes or No

    On The Job Injury: Yes or No

    Law Firm:

    Phone: ( )

    Case Worker Name: Phone: ( )

    Claim No.

    WORKER’S COMPENSATION COMPANY / MVA:

    Insured’s Date of Birth:

    PATIENT INFORMATION

    PERSON RESPONSIBLE FOR PAYMENT/ PARENT IF MINOR

    Name

    Home Address

    Mailing Address (if different) Email:

    Date of Birth

    Employer’s Name

    Referring Doctor

    General Dentist

    Social Security No.

    Orthodontist

    Sex M F Marital Status M S D W O Home Phone ( )

    Last First M.I.

    Street City State Zip

    Name

    Date of Birth

    Home Phone ( )

    Relationship to patient

    Address (if different)

    Soc. Sec. No.

    Employer Street

    Last First M.I.

    City State Zip

    EMERGENCY CONTACT (OTHER THAN PATIENT)

    Last First M.I. Name

    Address

    Relationship Phone No. ( )

    Work Phone. ( ) Street City State Zip

    MEDICAL INSURANCE (NEED COPY OF CARD)

    DENTAL INSURANCE (NEED COPY OF CARD)

    Primary Insurance Group No. ID No.

    Relationship to patient

    Group No. ID No.

    Employer

    Employer

    Relationship to patient

    Subscriber’s Name

    Subscriber’s SS# D.O.B.

    Subscriber’s SS# D.O.B.

    Subscriber’s SS# D.O.B.

    Secondary Insurance

    Subscriber’s Name

    INJURY INFORMATION

    I hereby authorize my physician to release any medical information necessary to process claims with any insurance companies. I also assign my physician all payments to which I am entitled for medical and surgical expenses related to the services reported herewith. I understand that I am financially responsible for all charges whether covered by insurance or not. I also understand that balances outstanding for more than 90 days will be subject to a processing fee. o Privacy Notice. I approve transfer of Medical and Dental records by email to my treating Dentist and Physicians.

    Pat. Reg 45 11/08

    X

    X

    X

    Phone ( )

    RELATIONSHIP TO PATIENT

    RELATIONSHIP TO PATIENT

    RELATIONSHIP TO PATIENT

    Primary Care Doctor

    Work Phone ( )

    Company Name:

    Phone ( )

    Phone ( )

    Phone ( )

    Phone ( )

    SIGNATURE

    SIGNATURE

    SIGNATURE

    o UPDATE

    o UPDATE

    o UPDATE

    DATE

    DATE

    DATE

    Cell Phone ( )

    PATIENT REGISTRATION

  • Permission for Verbal Communications

    Head and Neck Surgical Associates _________________________________________________________________________________________________ (Print name of patient) (Date Of Birth) _________________________________________________________________________________________________ (Street address) (City, state, zip code) _________________________________________________________________________________________________ (Phone number)

    I permit Head and Neck Surgical Associates, their physicians, nurses, and other personnel to discuss health information, in person or by telephone, with the following family members or friends involved in my medical care: (List family members/friends and state the person’s relationship to the patient).

    (Name) (Phone Number) (Relationship)

    1. ___________________________________________________________________________ 2. ____________________________________________________________________________________ 3. ____________________________________________________________________________________ 4. ____________________________________________________________________________________ 5. ____________________________________________________________________________________ Release of information under this document is limited to verbal discussions with my Health Care Providers. This document does not permit release of any written health information to the individuals named above. This authorization is limited to the following time frame from ______________ (date) to __________ (date). If no dates are indicated, this form will remain in effect for an unlimited amount of time. If, at any time, I do not want verbal discussions to be permitted between my Health Care Providers and any of the individuals named above, I must notify my Health Care Provider by contacting the Medical Records Department at 503-553-3650 Patient’s Signature: ________________________________________________ Date: ________________ If a representative on behalf of the patient signs this release, complete the following: Representative’s Name: __________________________________________________________________ Relationship to Patient: ___________________________________________________________________ Head and Neck Surgical Associates 1849 NW Kearney Suite 300 Portland, Oregon 97209 P. 503-553-3650 F. 503-224-9081 HNSA 93PVC

  • Health History Form

    Patient’s Name ______________________________________ Date of Birth _____/_________/___________

    Gender: Male / Female Height: _________ Weight: __________

    Page 1 of 2

    Your medical history is important to the treatment you will receive. Therefore, it is important that you respond to each question honestly and completely. Please circle your responses.

    Please describe your current health: Excellent Good Fair Poor Please describe the symptoms you are currently having today: ______________________________________________________________

    Have there been any changes in your general health in the past year? Yes No If yes, please describe: ______________________________________________________________________________________________

    Are you now under a physician’s care for a particular problem at this time? Yes No

    If yes, why? ___________________________________________ Date of last physical exam ____/______/_________

    Have you ever been hospitalized or had a serious illness? Yes No

    If yes, why?_______________________________________________________________________________________________________

    FAMILY MEDICAL HISTORY Do you have a family history of any of the following? If yes, indicate the relationship. Diabetes? Yes No Relationship ______________ Cancer? Yes No Relationship _____________

    Heart disease? Yes No Relationship ______________ Bleeding problems? Yes No Relationship _____________

    Tumors? Yes No Relationship ______________ Lung disease? Yes No Relationship ____________

    PATIENT MEDICAL HISTORY Do you have or have you ever had:

    Congenital heart disease, cardiovascular disease (heart attack, heart murmur, coronary artery disease, chest pain, high/ low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker)?

    Yes No Lung disease (asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)?

    Glaucoma?

    Yes

    Yes

    No

    No

    Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)?

    Yes No Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily?

    Yes No

    Kidney disease or kidney failure, requiring dialysis? Yes No Liver disease (jaundice, hepatitis A, B, or C)? Yes No

    Thyroid disease? Yes No Diabetes? Yes No

    Stomach ulcers or colitis? Yes No Arthritis? Yes No

    Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth?

    Yes No Significant weight loss or gain?

    Seizures, convulsions, epilepsy, fainting or dizziness?

    Yes

    Yes

    No

    No

    Frequent or recurring mouth sores? Yes No Sinus or nasal problems? Yes No

    Radiation to the head or neck for cancer treatment? Yes No Osteoporosis or osteopenia? Yes No

    Any disease, chemotherapy or transplant operation? Cancer? Yes No If so, where? _______________________________________, and when was the date of your last treatment? _______________________

    Do you have any other disease, condition or problem not

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