ENDOCRINOLOGY MEDICAL GROUP OF ORANGE COUNTY, INC.

725 W. La Veta Avenue, Suite 220 Orange, CA 92868

PATIENT REGISTRATION FORM NAME (LAST, FIRST INIT.)

ADDRESS CITY STATE ZIP CODE

HOME PHONE NO. CELL PHONE NO. EMAIL DATE OF BIRTH

SOCIAL SECURITY NO. SEX (M / F) MARITAL STATUS

OCCUPATION EMPLOYER

EMPLOYER ADDRESS CITY STATE ZIP CODE

EMPLOYER PHONE NO. REFERRING PHYSICIAN EMPLOYER ADDRESS

PRIMARY INSURANCE INSURANCE NAME & ADDRESS IN CASE OF EMERGENCY CONTACT PERSON

SUBSCRIBER NO. GROUP NO.

RELATIONSHIP PHONE NO.

INSURED’S NAME INSURED’S PHONE NO. INSURED’S PHONE NO.

INSURED’S SOCIAL SECURITY NO.

INSURED’S EMPLOYER

EMPLOYERS ADDRESS CITY STATE ZIP CODE

SECONDARY INSURANCE INSURANCE NAME & ADDRESS

SUBSCRIBER NO. GROUP NO.

INSURED’S NAME INSURED’S DATE OF BIRTH

INSURED’S PHONE NO. INSURED’S SOCIAL SECURITY NO.

INSURED’S EMPLOYER

EMPLOYERS ADDRESS CITY STATE ZIP CODE

HOW DID YOU HEAR ABOUT US?

INSURANCE:____________________________

FAMILY MEMBER:_______________________

YELP.COM

HEALTHGRADES.COM

DOCTOR:________________________

FRIEND:_________________________

OTEHR:________________________

I authorize payment of medical benefits be made directly to the physician provider for services rendered.

DATE SIGNED (Insured or Authorized)

I authorize any insurance company, organization, employer, hospital, physician, or pharmacist to release any information to this claim and the

expenses reported.

DATE SIGNED (Insured or Authorized)

ENDOCRINOLOGY MEDICAL GROUP OF O.C., INC

725 W LA VETA AVENUE #220

ORANGE, CA 92868

714-771-5700

PATIENT HISTORY

DATE: ______________

NAME: ____________________________________________AGE____BIRTHDATE_______________

OCCUPATION: ________________________________ REFERRED BY__________________________

REASON FOR VISIT__________________________________________________________

MEDICATION AND DOSAGES: ALLERGIES:

_____________________ __________________ __________________ _____________

_____________________ __________________ __________________ _____________

_____________________ __________________ __________________ _____________

_____________________ __________________ __________________ _____________

_____________________ __________________ __________________ _____________

IMMUNIZATIONS AND DATES:

Tetanus_______ Flu Shot________ Pneumonia Vaccine ________TB Skin test ________Hepatitis______

SOCIAL HISTORY:

Birthplace_______________________________Education_______________________________

Ever smoked? _______Do you still smoke? _____ How many packs per day? _________

Alcoholic Beverages? _____________ Coffee/Tea/Soda? ______ How many cups per day? _________

SURGERIES AND DATES

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

HOSPITALIZATIONS AND DATES

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

DOCTORS SEEN IN THE PAST TWO YEARS AND REASON FOR VISIT

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

3. ____________________________________________________________________________________

4. ____________________________________________________________________________________

PAST MEDICAL HISTORY

Diabetes_______ Hepatitis_______ Hypertension_____ Stroke ______ Cancer ______ Thyroid ______

Anemia________ Asthma_______

Transfusions __________ Pregnancy___________

PATIENT SIGNATURE______________________

Page 1 of 2 Consent Form

ENDOCRINOLOGY GROUP OF ORANGE COUNTY, INC.

725 W. La Veta Ave., Suite 220

Orange, CA 92868

CONSENT FORM

Patient: ________________________________________ Date: _______________

In connection with the medical services that I am receiving, I hereby authorize Drs. Rettinger,

Dr. Shah, Dr. Rockoff, their respective agents, and staff to disclose any and all information

concerning my medical condition and treatment (including, but not limited to, super-

confidential information concerning sexually transmitted diseases, mental health, chemical

dependence, or other such information), including copies of applicable hospital and medical

records, to:

A. Any third party payer covering the medical services of the patient;

B. Other health care professional and institutions involved in the delivery of health care to

the patient;

C. The proponent of any legally sufficient subpoena, or in response to a court order;

D. Employees and agents of the practice, to the degree necessary to facilitate the provision

of health care services and payment for such services;

E. Pharmacies; and

F. As otherwise required by law.

When providing information to me, information may be transmitted by any and all of the

following means (initial all that apply):

________ Telephone messages on an answering machine or voicemail

________ Messages to the following family members or friends:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Page 2 of 2 Consent Form

In each case, the practice shall take reasonable steps to ensure that only the minimum

necessary information is disclosed in accordance with the above. I further understand that I

have been given access to the physician’s privacy notice and that I have had the opportunity to

place special instructions upon the consent hereby given:

Special Instructions:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I understand that regardless of my insurance coverage, I am ultimately responsible for

payments on my account with Endocrinology Medical Group of O.C., Inc. All co-pays and

deductibles are to be paid at the time of service. If I have no insurance coverage, payment is

required at the time of service. Should there be any problem in collecting from my insurance

company, I understand that I am responsible to call my insurance company and resolve the

matter promptly. Should the insurance check be sent to me in error, I understand that I am to

remit it to Endocrinology Medical Group of O.C., Inc. and any balance so remaining. Should my

claim for coverage be denied for any reason, I understand that I am responsible for payment in

full to Endocrinology Medical Group of O.C., Inc. I am responsible to inform them of any change

in my insurance coverage as well.

This consent is valid from the date executed until revoked in writing by the patient.

Signed: ________________________________________________

Date: ________________________

Witness: _______________________________________________

ENDOCRINOLOGY GROUP OF ORANGE COUNTY, INC.

FINANCIAL AND APPOINTMENT POLICIES

Thank you for trusting your Endocrine needs to Endocrinology Group of Orange County, Inc. We

strive to provide excellent medical care to all of our patients. Informing you in advance of our

office policies allows for better communication between our patients and office. If you have any

questions, please do not hesitate to ask a member of our staff.

1. According to your insurance plan, you are responsible for any and all co-payments, co-

insurance and deductible payments. These amounts are not negotiable and will be

collected at the time of service. If you are a cash patient, full payment is due at the time

of service (no exceptions).

2. As a courtesy, we verify your insurance prior to your visit. This is not a guarantee of your

eligibility. It is your responsibility to understand your benefit plan. It is your

responsibility to know if a prior authorization is needed for a procedure and what

services will be covered. We will assist with this process; but we are not responsible for

the ultimate payment determination by your insurance carrier.

3. You agree to pay all cost of collection including reasonable attorney fees and court costs

should you fail to pay the amount owed when due.

4. We require 24 hours’ notice for cancelling appointments. If you fail to notify us per this

policy, you will be charged a $30.00 fee which is payable prior to rescheduling.

5. In order for our office to run as efficiently as possible, we ask that all patients be on time

for their appointments. Patients that arrive more than 10 minutes late may be asked to

reschedule to an open appointment slot for the same day. If there is no open

appointment time slots for the same day, the patient may be asked to reschedule to

another day.

6. A $20.00 fee is charged for all NSF checks in addition to any bank fees incurred.

7. We charge a $50.00 fee to fill out forms. The payment is due in advance and we require

up to 5 business days for completion.

I have read and understand the Financial and Appointment Policies and agree to comply and

accept responsibility for any payment that becomes due as outlined above.

_____________________________________

Patient Name

_____________________________________

Responsible Party Name Relationship

_____________________________________

Responsible Party Signature Date

Endocrinology Medical Group of Orange County

Cancellation Policies

1. Cancellation

If you need to change or cancel an appointment, please call to cancel at

least 24 hours prior to your scheduled appointment time. This will allow us

to fill your appointment with another patient who needs our care. Failure

to cancel 24 hours in advance will result in a cancellation fee of $30.

2. Failure To Come To A Scheduled Appointment

Here at E.M.G.O.C., we strive for excellence in patient care. When you are

scheduled for an appointment, we prepare for your visit. Failure to come to

a scheduled appointment will result in a $30 fee. Please call to cancel at

least 24 hours prior to your scheduled appointment time.

Patient Name (please print): ____________________________

Patient Signature: _____________________________________ Date: _____________

NAME: _________________________________________ DATE: __________________

ETHNICITY:

o AMERICAN INDIAN o AFRICAN AMERICAN o NATIVE HAWAIIAN o ASIAN

o HISPANIC/ LATINO o WHITE o REFUSE

LANGUAGE PREFERENCE:

o ENGLISH o SPANISH o CHINESE o FRENCH o GERMAN o ITALIAN

o JAPANESE o KOREAN o PORTUGUESE o RUSSIAN o OTHER ___________________

TOBACCO USE:

HAVE YOU EVER SMOKED? YES NO CURRENT SMOKER? YES NO IF SO, FOR HOW MANY YEARS? ___________ HOW MANY PACKS DAILY? __________ FORMER SMOKER: HOW MANY YEARS AGO DID YOU QUIT? _____________

PHARMACY PREFERENCE:

______________________________________________________________________________

(NAME ADDRESS CITY ZIP CODE)

MEDICATION LIST (PLEASE INCLUDE SUPPLEMENTS AND OTCS) OR PLEASE ATTACH YOUR OWN MEDICATION LIST.

MEDICATION NAME STRENGTH DOSE FREQUENCY

ALLERGIES: ____________________________________________________________________

LAB FACILITY NAME: DATE OF LAST LAB:______________ __

RADIOLOGY (ULTRASOUND/ X-RAY/ SCANS): LOCATION: _ DATE OF MOST RECENT:________ ____