Daoud Surgery and Family Medicine, PC

Available Forms

Child Complete Physical Health History form Complete Physical Health History form Consent for Teleheath Visit Female Complete Physical Health History form Male Complete Physical Health History form Parental Permission Form REGISTRATION INFORMATION FORM

REGISTRATION INFORMATION FORM

PATIENT INFORMATION

Patient First Name *

Patient Middle Name

Patient Last Name *

Birthdate *

(MM/DD/YYYY)

Social Security Number *

Age *

Marital Status *

Street Address *

State *

Zip Code *

Phone Number

Cell Number

E-mail address

Language *

English

Spanish

Arabic

Japanese

Other

Pick all you speak fluently

Race or Ethnicity *

Non Hispanic White or Euro-American

Black or African American or Afro-Caribbean

Hispanic or Latin American

East Asian or Asian American

Middle Eastern or Arab American

Native American or Alaskan

Native Hawaiian or other Pacific Islander

Two or more races

Other

Pick all that you Identify with

If other picked for language, race or ethnicity, please explain

Explain if you chose other above.

WORK INFORMATION

Employer *

Please mark student, homemaker, unemployed, if the patient doesn't work

Work Number

Is it OK to call work

SPOUSE INFORMATION

Spouse Name

We need this information if they are an insurance holder in order to bill your insurance

Spouse Birthdate

(MM/DD/YYYY) We need this information if they are an insurance holder in order to bill your insurance

Spouse Social Security Number

We need this information if they are an insurance holder in order to bill your insurance

FILL THIS SECTION IF CHILD IS A MINOR (or parent/guardian insurance is used)

Mother's Name (first and last)

First and Last Name of Mother<br/>

Mother's Birthdate

Date of birth of mother (MM/DD/YYYY)

Mother's Social Security Number

Social Security Number of Mother

Father's Name (first and last)

First and last name of Father

Father's Birthdate

Date of Birth of Father (MM/DD/YYYY)

Father's Social Security Number

Social Security Number of Father

EMERGENCY CONTACT

Name (First and Last)

Phone Number

Relationship to you

Spouse, parent, child, friend, fiancee, etc

Pharmacy Used

List the pharmacy or pharmacies used

Pharmacy's City

Pharmacy's State

Pharmacy's Number

COMMUNICATION OF RESULTS

I understand that ideally my test results will be communicated to only me. However, in the event I am unavailable, I grant permission to the staff to communicate my results to me in the following manner.

Test Results can be given *

Only to me (if nothing else checked)

On my answering machine

Check any you wish to authorize.

The following people may be given my test results if I am unavailable. I also give permission to talk to them related to my health. (NOTE: Since many people want family members and some friends to have knowledge about their health, we will consider that it is OK to answer their questions regarding your health if you write their names in this area. Therefore, we will not be in HIPAA violation should something be said that you didn't want disclosed.)

First and Last Name of person with whom it is okay to discuss my health

First and Last name

Relationship to patient

Spouse, Parent, child, fiance, significant other, friend, etc

Phone Number

First and Last Name of person with whom it is okay to discuss my health

Second Person -First and Last Name<br/>

Relationship to patient

Spouse, Parent, child, fiance, significant other, friend, etc

Phone Number

ASSIGNMENT OF INSURANCE BENEFITS AND/OR SELF PAY AGREEMENT

The undersigned hereby authorizes the release of any information relating to all claims for benefits on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered, without obtaining my signature on each claim that is submitted for myself and/or dependents. I will be bound by this signature as though the undersigned had personally signed the particular claim. This includes services rendered in the office as well as telehealth and phone visits. I the undersigned hereby authorize my above INSURANCE COMPANY to pay and hereby assign directly to Daoud Surgery and Family Medicine all benefits, if any, otherwise payable to me for his/her service as described on the attached forms. I understand that I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits when received by and paid to Daoud Surgery and Family Medicine will be credited to my account, in accordance with the above said statement. Should I not have insurance or they do not cover all fees, I promise to pay all debts that occur from services I received. By typing my name below with birthdate and today's date counts as my e-signature and my agreement to the above.

First Name Signature *

Write the first name of your e-signature

Last Name of Signature *

Write the last name of your e-signature

Birthdate of the person signing the form *

Write in your birthdate (MM/DD/YYYY)

Today's Date *

Write in today's date (MM/DD/YYYY)

* Required field