Regional PhysiciansPRIMARY CARE

tm High Point Regional Health System

Adams Farm Shopping Center5710-1 High Point RoadGreensboro, NC 27407Phone: (336) 299-7000Fax: (336) 299-7003

Welcome to Regional Physicians Primary Care. We are pleased that youhave chosen us to be your primary care provider.Enclosed you will find our New Patient Packet.

In order for us to schedule your appointment we need you to thoroughlycomplete the enclosed packet and return to us via mail, fax or you may dropit off at our office. We are open M-F from 8-5 and are closed between12-1pm for lunch. It is VERY IMPORTANT that the last two pages of thepacket be completed in full. In the event that these two fonns are notcompleted in full, we will return them to you for proper completion prior toscheduling your appointment.

If you are transferring your healthcare from another provider or facility toour office, you may contact that physician or facility to have them transferyour records to us.However, for your convenience there is a "release ofmedical records"enclosed. Ifyou would like for us to request your records, please completethis fonn in its entirety.*Please note: Children ages 18 & under- we MUST have their immunizationrecord(s) prior to their scheduled appointment.

As a new patient, please arrive 30 minutes prior to your scheduledappointment. Bring your insurance card, photo ill, any necessary eyeglassesand ALL medications in their original containers. Copays and deductiblesare due at the time of service. Ifyou do not have insurance you will beresponsible for payment in full at the time ofyour visit.

Thank you again for choosing Regional Physicians Primary Care. We lookforward to serving your healthcare needs.

REGIONAL PHYSICIANS PRIMARY CAREAdams Farm Shopping Center

5710-1 High Point RoadGreensboro, NC 27407

Phone: (336) 299-7000 Fax: (336) 299-7003

PATIENT INFORMATION

Social Security No.: _ Patient's Full Legal Name: _

I.:ISI)( First Middle

Sex: _F _M Birth Date __'__' Race: Spoken Language: _

Marital Status: Single_ Married_ Widowed_ Divorced_ Separated_

Zip Code

Address: _Street City

Employer: Address: _

Home Phone: ( ) Work Phone: ( ) Cell Phone:( ) _

Email: Referring Provider Name: _

How did you hear about us? (circle all that apply) Family / Friend / Insurance / Employer/ Internet / WebsiteIBlllboardl

Newspaper !Mailer !Radio /Seminar/ Sports Team Support' TVI Yellow Pages

Primary Insurance:. Subscriber ID: _

Subscriber Name: Group #: _

Subscriber's Soc. Sec. 1#: Subscriber's Date of Birth: _

Secondary Insurance: Subscriber ID: _

Subscriber Name: Group #: _

Subscriber's Soc. Sec. 1#: Subscriber's Date of Birth: _

"*Please have your insurance card(s) and photo ID ready to be copied.*..

Spouse's Name: Work Phone: ( ), _ Cell Phone ( ) _

Emergency Contact: ~Relationship: _

Home Phone: ( ) Work: ( ) Cell: ( ) _

IF PATIENT IS UNDER 18 YEARS OLD, PLEASE COMPLETE PARENT/GUARDIAN SECTION BELOW.

Parent/Guardian Name: _

Address: _

(If different from above) Street City State Up Code

Home Phone: ( ) Work: ( ) Cell: ( ) _

Social Security #: Date ofBlrth: Sex: .F __~M

Marital Status: Single__ Married __ Widowed __ Divorced __ Separated__

The undersigned makes the following acknowledgments and agreements regarding treatment to be provided to the patientwhose name appears above:

I - Consent to treatment: I consent to any medical or surgical treatment rendered to the patient under general or specialinstructions of the physician. I certify that no guarantee of assurance has been made to me as to the results which may beobtained.

2 - Release of medical information: I authorize the release of any medical or other infonnation from this provider andother providers necessary to process a health insurance claim or to provide treatment.

3 - Assignment of benefits: I authorize payment of medical benefits to MedVentures, LLC DBA Regional Physicians.

I certify that the information given at the time of registration is correct. I understand that I will be financially responsiblefor all charges in full at the time I am given treatment unless otherwise discussed before I am seen. I understand I amfinancially responsible to Regional Physicians for charges not covered by insurance.

Signature of Patient or Legal Representative DatemasOS0610

Regional Physicians Primary CareAdams Farm Shopping Center

5710-1 High Point Road, Greensboro, NC 27407(336) 299-7000 Fax: (336) 299-7003

Notice of Privacy Practices Receipt Acknowledgement

I have been presented with a copy of Regional Physician's Notice of Privacy Practices, detailinghow my health information may be used and disclosed as permitted under federal and state law.I understand the contents of the notice.

Patient Name (Printed)

Signature of Patient or Guardian (If minor)

Date of Birth

Date

1. Please list the family members and/or other persons, if any, whom we my inform about yourgeneral medical condition and your diagnosis (including treatment, payment and health careoperations):

Name: Phone #: _

Name: Phone #: _

Name: Phone #: _

2. Please list the family members and/or other persons, if any, whom we may inform about yourmedical condition ONLY IN AN EMERGENCY:

Name: Phone #: _

Name: Phone #: _

Name: Phone #: _

3. Please list the telephone number(s) where you want to receive calls about your appointments, laband x-ray results, or other health information:

4. Can confidential messages (i.e. appointment information) be left on your answering machine?

_______ Yes _______ No

It is your responsibility to update this information as needed•

•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Intemal Use OnlyIf patient or patient's representative refuses to sign acknowledgement of receipt of Notice, please document the date and time the Notice was presentedto patient and sign below:Presented on (date): Namerritle: _

REGIONAL PHYSICIANS PRIMARY CARE

Adams Fann Shopping Center5710-1 High Point RoadGreensboro, NC 27407Phone: (336) 299-7000

Fax: (336) 299-7003

CONSENT FOR RELEASE OF MEDICAL RECORDS

From: Patient's Name

Patient's Address

Patient's Birth Date

Patient's Social Security Number (last" digits only) XXX - XX - _

Records Requested From:

PracticelPhysician Name

Address

Phone

I do hereby consent and authorize you to release copies of my medical records. PLEASE NOTE: Thisauthorization includes consent for the release of alcohol, drug, psychiatric infonnation, and any infonnation relatingto HIV testing, AIDS, and AIDS-Related Syndrome, which may be included in my records. It also may includeinfonnation concerning cancer, cancer testing, and cancer results. I agree that a copy of this release or a fax ofthisrelease shall be as valid as the original. Please send copies ofall requested infonnation as soon as possible to theaddress listed below.

Send all my records

Sensitive infonnation has been deleted at the patient's request

Send records from (date) _

SEND RECORDS TO: _

PurposelUse oftbe Requested Information_2nd Opinion_Sharing with other Health Care Provider_Transfer of Care (Patient Sign Discharge Letter to Terminate Care)

Patient's Signature _

Witness

Date _

Physician Signature _

revjcJ2J809

For office use only:

Appointment Dale: _Appointment Time: _Provider:Scheduler'~s"""in""'it"""ial:-s:-----

trnRegional PhysiciansHIGH POINT REGIONAL HEALTH SYSTEM

Medical History FormPlease complete §1!. Information on this form to the best ofyour knowledge.

If none In a particular section, write nla or none.

Patient Name: Date of Birth: _

Name of person completing form: Date: _

Past Medical History: (Please check all Items that you have had In the past)a Alcohol abuse a Depression a Hypertension 0 Kidney disease 0 Thyroid diseasea Anemia a Diabetes 0 Mononucleosis 0 Liver disease a Migraine headachesa Arthritis a Heartburn 0 Seizure Disorder 0 Multiple Sclerosis 0 STD: _a Asthma a Heart Disease a Stroke 0 Parkinson's disease aa Cancer: 0 Hernia a Tuberculosis 0 Alzheimer's disease 0-------

o COPD 0 High Cholesterol 0 Urinary tract infection a Chronic pain a _

Allergies: (List allergen name and the type of reaction, write n/a If none)

Medication (s): Reaction: _

Medication (s): Reaction: _

Food/Insects/Other: Reaction: _

Immunizations: (List month/year of last Immunization)

Tetanus: Hepatitis B: Other:Gardasil: Meningitis: Other:Hepatitis A: Shingles: Other:

Family History: (List any major medical conditions that your Mother, Father, Brothers, Sisters, MaternalGrandparents, Paternal Grandparents, Aunts, and Uncles may have. Example Mother/Diabetes)

II

1

No How many alcoholic drinks per week? _-::-__No Packs Per day: How long? _No What year did you quit? .,.....-__..,...,...__No Passive smoker? Yes NoNo Caffeine Use? Yes No How much? _

-----_./_------- .1 -

------_./_-----

Education: _

If yes: xlweek Type: _No

YesYesYesYesYes

-----~/_----------_./_-----_____~/ -

Social History:Habits:Do you drink alcohol?Cigarette smoking?Past smoking?Chewing tobacco?Any drug use?

Marital Status: _

Occupation: _

Exercise? Yes

Present Medications: (List the name and dose of each medication you are currently taking.)

Surgeries: (Check all surgeries that you have had.)a Appendectomy (appendix) a Inguinal hernia repaira Breast Mass a Laminectomyo Cataract a Lumpectomyo Cholecystectomy (Gall bladder) °Mastectomyo Coronary Artery Bypass °Prostatectomy (prostate)o Hysterectomy °Thyroidectomy (thyroid)

o Tonsillectomy (tonsils)o Umbilical hernia repairo Vasectomy0 _

0 _

0 _

0 _

0 _

0 _0 _

0 _

0 _

Health Maintenance: (List month/year of last screening/evaluation)

Colonoscopy: Last Pap: Bone Density:Flu Vaccine: Pneumonia Vaccine: Cholesterol:Mammogram: PSA: Other:

Symptoms: (Check all symptoms that you currently have)

General: Neck: Female Genitourinary: Endocrine:Chills Neck Mass _ Pelvic pain _ Appetite changesFair Health Neck Pain _ Urinary Complaints Excessive thirst

_ Fatigue Swollen Glands _ Vaginal bleeding problem Hot flashesFever _ Vaginal dischargeGood Health Respiratory: Hematology:

_ Night sweats _Cough Male Genitourinary: AnemiaPoor Health _ Coughing up blood Blood in urine _ Blood clots in legs

_ Sleep difficulties Shortness of breath _Impotence_ Weight Gain _ Sputum production _ Penile discharge_Weight Loss _ Wheezing _ Urination difficulty

Skin: Breast: Musculoskeletal:_Bruising _ Breast pain _Joint pain_ Changes in Moles _ Breast lump _ Muscle pain_Dryness _ Nipple discharge Muscle weakness

Hair Loss _ Swelling of area: ___Itching/Rash Cardiovascular:

New lesions _Chest pain Neurological:_ Scalp problems _ Chest pressure Dizziness_ Yellowing of skin _ Palpitations _ Fainting spells

HeadachesEye/Ear/NoselThroat: Gastrointestinal: _ Memory problems

Earache _ Abdominal pain Numbness_ Gums bleeding _ Black, tarry stool Seizures_ Hearing decreased _ Constipation Tremors

Nose bleeds Diarrhea Weakness_ Ringing in ears _ Difficulty swallowing_Runny Nose Nausea Psychiatric:

Sinus Pain _ Rectal bleeding _AnxietySore Throat _ Vomiting _ DepressionThroat hoarseness _ Vomiting blood _ Mood swingsVisual disturbances

Do you have any specific questions that you want your doctor to address? _

Preferred Pharmacy: Address: _