Formulario De Registro Del
Paciente
Information Del Paciente
Sexo:  Masculino
 Femenino
Apodo
Nombre (Primero, Segundo, Apellido)
Fecha De Nacimiento
Seguro Social
Estado Civil:  Soltero  Casado  Separado  Divorciado
 Viuda(o)
Direccion:
Telefono de casa:
(calle, ciudad, codigo postal, condado)
Cellular:
Trabajo:
Correo Electronico:
Estado De Empleo:  Tiempo Completo
 Medio Tiempo
 Servicio Activo
 Trabajador Cuenta Propia
Retirado Nombre de Empleador:
 Desempleado
Numero De Empleador:
Direccion De Empleador:
(calle, ciudad, codigo postal, condado)
 Mismo Que El Paciente
Conyuge O Garante De Information (Persona Responsable)
Nombre (Primero, Segundo, Apellido)
Relacion Con Paciente:  Yo
Fecha De
Nacimiento
 Esposa(o)
Telefono De Casa:
 Madre
 Padre
 Tutor Legal
Cellular:
Direccion Postal Completa – :
Si es differente del paciente
Estado De Empleado:  Tiempo Completo
Nombre De Empleador:
SeguroSoci
 Otro:
Sexo:  Masculino  Femenino
Trabajo:
(calle, cuidad, codigo postal, condado)
 MedioTiempo
 Servicio Activo
 Trabajador Cuenta Propia  Desempleado Retirado
Numero De Empleador:
Direccion de empleador:
(calle, ciudad, codigo postal, condado)
INFORMATION DEL SEGURO
 SIN SEGURO
Seguro Primario:
Relacion al suscriptor:  Yo
 Esposa(o)
 Hija(o)
 Otro:
Seguro Secundario:
Relacion al suscriptor:  Yo
 Esposa(o)
 Hija(o)
 Otro:
Proveedor de prescription:
(Si es differente de la compania de seguros)
Nombre completo del suscriptor(Si es differente al paciente:
Estado de empleo:  Tiempo completo
 Medio tiempo
Fecha de nacimiento:
 Servicio activo
 Trabajador cuenta propia  Desempleado
Nombre de empleador
Direction de empleador:
(calle, ciudad, codigo postal, condado)
CONTACTO DE EMERGENCIA
Nombre (completo):
Relacion con el paciente:  Esposa(o)
Numero de telefono:
126522P Rev. 04/14
 Madre
 Padre
 Tutor Legal
Direccion postal completa:
DO NOT SCAN
 Otro:
 Retirado
HISTORIA MEDICA
Nombre Completo:
Fecha De Nacimiento:
Fecha:
Doctor de cabecera:
ALERGIAS Y REACIONES
MEDICAMENTOS- (Lista de dosis y como tomar
los, Incluyendo hierbas y control de natalidad))
PASADAS ENFERMEDADES MEDICAS (porfavor marque si ha tenido los siguiente)
 Alcohol/adiccion de drogas
 Anemia
 Aneurisma
 Artritis
 Asma
 Coagulo de sangre
 Desorden sanguineo
 Transfusion de sangre
 Transtorno de ansiedad
OPERACIONES
DATES
 Cancer (tipo):
 Gota
 Calculos renales
 Stroke
 Pecho  Ovarios
 Fiebre de heno
 Enfermedad de higado  Tiroides
 Colon  Uterino
 Enfermedad del corazon  Incautacion
 Tuberculosis
disease
(type):
 Crohn
 Hepatitis B or C
 Ulcerative colitis
 Enfisema
 High cholesterol
 Apnea de sueno
 Diabetes
 Hipertension
 Celulas falciformes
 Depresion
 VIH
 Ulcera estomacal
 Glaucoma
 Enfermedad del rinon
 Soplo de corazon
 Enfermedad de transmission sexual
FECHAS
HOSPITALIZACIONES
FECHAS
HISTORIAL DESALUD FAMILIAR  Adoptado
Miembros dela familia
Problemas Medicos
Abuela Materna
Abuela Paterna
Abuelo Materno
Abuelo Paterno
Madre
Padre
Hermana(o)s
1)  M  F
2)  M  F
3)  M  F
Hija(o)s
1)  M  F
2)  M  F
3)  M  F
125842P Rev. 08/13
Si fallecidos / causas
Edad de fallecido
Historia Social
Ocupation:
Estado civil:
Bebes alcohol?
 SI  No
Con que frecuencia?
Fumas?
 SI  No
Paquetes al dia:  ¼ paquete  1½ paquete
Ex-fumador?
 SI  No
 ½ paquete  2 paquete
Do you chew tobacco?
 SI  No
 1 paquete  Otro:
Usas drogas recreacionales?  SI  No
Has trabajado con el aminato o otros materiales peligrosos?
Mantenimiento de salud
Ultimo periodo:
Ultima colonoscopia:
Vacunas  Pneumovax:
 SI
 No
Ultimo papanicolau:
Ultima mamografia:
Ultimo examen de prostata:
 Gripa:
Hija(o)s:  Si  No
Cuantas bebidas?
Cuantos anos ?
ano renuncia?
 Tetanos:
Ultima prueba de den:
 Hep A:
 Hep B:
Revision de sintomas (por favor, compruebe si recientemente ha tenido los siguientes sintomas):
 Aumento de peso
 Perdida de peso
 Sudores nocturnos
 Debilidad
 Fatiga
 Insomnio
 Cambios de audicion
 Cambios en la vision
 Secrecion nasal
 Corrimiento de nariz
 Fiebre
l
 Sangre en esputo
 Falta de aliento
 Molestias en el pecho
 Retenimiento de orina
 Dolor de cabeza
 Tos persistente
 Dificultar para orinar
 Perdida de memoria
 Palpitaciones
 Problemas para retener orina  Entumecimiento/hormigueo
 Desmayo
 Frecuencia de la miccion
 Temblor
 Cambio en tolerancia al ejercicio  Descarga del pene
 Cambios de humor
 Dificultad para pasar alimentos  Flujo vaginal/sangrado
 Ansiedad
 Ardor estomacal
 Secrecion del pezon
 Depresion
 Nauseas
 Dolor de mama
 Erupcion de la piel
 Vomito
 Tumor de seno
 Dolor de espalda
 Cambio del habito intestinal
 Dolor durante sexo
 Dolor en las piernas
 Diarrea
 Se siente demasiado frio
 Inflamacion de las piernas
 Estrenimiento
 Se siente demasiado caliente  Otro:
 Sangre en el vomito
 Mareos
Verificacion de la information : Yo verifico que la information arriba proporcionadaes
verdadera y correcta alo major de mi conocimiento. Yo por la presente autorizo la facilidad para
aceptarla asignacion de beneficiosde seguroy entiendo que soy responsible de co-seguro,
copagos y/o deductibles en el momento del servicio. Yo entiendo que si mi seguro es un plan no
contratado la instalacion de cortesia la demanda por los servicios prestados. En el caso de que
no tengo ni la cobertura del seguro, entiendo que el de los honorarios deben ser pagadosal
servicio de tiempo. Yo entiendo que se pedira alos saldos adeudados anteriores a la instalacion
en el momento de la inscription.
__________________________________________________________
Firma del paciente, padre o tutor legal
Fecha
Patient Authorizations and Consent
CONSENT ALLOWING PRESTIGE URGENT CARE CLINIC TO EVALUATE AND
I give my consent to Prestige Urgent Care Center and all of its representatives, including
by not limited to physicians, employees and affiliates, to perform the necessary
examination(s) or other medical treatments deemed appropriate by a Prestige Urgent
Care Center physician. I understand that certain medical exams or procedures may not be
intended for the purpose of a medical diagnosis and/or treatment, or to replace the
medical care of my primary care physician or specialist(s).
AUTHORIZATION TO PERFORM SUBSTANCE ABUSE TESTING
(when applicable)
I authorize Prestige Urgent Care Center to obtain, when necessary, a specimen of my
bodily fluids (blood, sal iva or urine), hair and/or any other specimen needed to conclude
whether or not drugs or alcohol are present in my body. I also authorize that these results
may be released to my employer, a prospective employer or to the party which I have
indicated here:
CONSENT TO ABIDE BY PRESTIGE URGENT CARE CLINIC FINANCIAL
POLICIES
I authorize Prestige Urgent Care Center to receive any and all payments for services
rendered under the terms of my insurance policies.I understand that I am responsible for
all other payments, including insurance co-payments, which must be paid at the time
services are rendered.
By signing this consent agreement, I acknowledge that I have read and fully understand
this form, or have had it explained to me by a Prestige Urgent Care Center representative
and understand its meaning. A Prestige Urgent Care Center representative has given me
the opportunity to ask questions regarding company policies, to which I have been given
satisfactory answers.
Signature of Patient, Parent, or Legal Guardian
Date
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We are committed to protecting medical information about
you. This Notice describes our privacy practices and that of
all its employees and staff. This Notice will tell you about the
ways In which we may use and disclose medical information
about you. It also describes your rights and certain
obligations we have regarding the use and disclosure of
medical information. We are required by law to:
•
•
•
Give you this Notice of our legal duties and privacy
practices with respect to medical information about
you
Make sure that medical Information that identifies you
Is kept private; and
Follow the terms of the Notice that is currently in
effect.
HOW WE MAY USE AND DISCLOSE MEDICAL
INFORMATION ABOUT YOU
The following categories describe different ways we use and
disclose medical information. For each category we will
explain what we mean and try to give some examples. Not
every use or disclosure in a category will be listed. However,
all of the ways we are permitted to use and disclose information will fall within one of the categories.
Treatment. We may use and disclose medical information
about you to provide you with medical treatment or services.
For example, a specialist we may refer you to may need to
know about a treatment you received at our office in order
to coordinate other treatments you are receiving.
Payment We may use and disclose medical information
about you so that the treatment and services you receive at
our office may be billed and payment may be collected from
you, an Insurance company or a third party. For example,
we,may need to give your health plan information about
services you received at our office so your health plan will
pay us or reimburse you for the services.
Health Care Operations. We may use and disclose medical information about you for our office operations. These
uses and disclosures are necessary to run our office and
make sure that all of our patients receive quality care. For
example, we may use medical information to review our
treatment and services and to evaluate the performance of
our staff in caring for you.
Appointment Reminders. We may use and disclose
medical information to contact you as a reminder that you
have an appointment for treatment or medical care at our
office.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible
treatment options or alternatives that may be of interest to
you.
Health-Related Benefits and Services. We may use
and disclose medical information to tell you about
health-related benefits or services that may be of interest
to you.
Individuals Involved in Your Care or Payment for
Your Care. We may release medical information about
you to a close personal friend or family member who is
involved in your medical care or payment for your care, so
long as you have not objected and it is reasonable for us to
infer that such disclosure is in your best interest.
Special Purposes When Permitted or Required by
Law. We may disclose medical information about you as
for special purposes when permitted or required by law,
including the following:
• To avert a serious threat to health or safety against you,
the public or another person.
• For public health and administrative oversight activities
such as disease control, abuse or neglect reporting, health
and vital statistics, audits, investigations, and licensure
reviews.
• For organ and tissue donation and transplant to facilitate
organ or tissue donation and transplant.
• For research purposes limited information may be
disclosed as permitted by law.
• To workers' compensation or similar programs for the
payment benefits for work-related injuries.
• To coroners, medical examiners and funeral directors to
identify a deceased person, determine cause of death, or
to carry out duties,
• To comply with court orders, judicial proceedings, or other
legal processes related to law enforcement, custody of
inmates, legal and administrative actions, and criminal
activity.
• For U.S. military and veteran reporting regarding members and veterans of the armed forces of U.S. or foreign
military.
• For national security and intelligence activities such as
protective services for the President and other authorized
persons.
State and Other Federal Laws. We will comply with all
applicable State and Federal laws. For example, under State
law, there are more limits on the disclosure of HIV and AIDS
information, We will continue to abide by all applicable state
and federal laws.
Other Uses of Medical Information Rewire an
Authorization, Other uses and disclosures of medical
information not covered by this Notice or the laws that apply
to us will be made only with your written authorization. If you
provide us en authorization to use or disclose medical
information about you, you may revoke that authorization,
in writing, at any time. If you revoke your authorization, we
will no longer use or disclose medical information about you
for the reasons covered by the written authorization. You
understand that we are unable to take back any disclosures
we have already made with your authorization, and that we
are required to retain our records of the care that we provide
to you.
YOUR RIGHTS REGARDING MEDICAL INFORMATION
ABOUT YOU
You have many rights with regard to your medical
information. if you wish to exercise any of these rights, you
must submit your request in writing, unless otherwise noted.
Your Right to inspect and Copy. You have the right to
inspect and copy medical information that may be used to
make decisions about your care. We may charge a
reasonable fee for the costs of copying, mailing or other
supplies associated with your request.
Your Right to Amend. if you feel that medical information
we have about you is incorrect or incomplete, you may ask
us to amend the information. You have the right to add a
statement. You must provide a reason that supports your
request for an amendment.
Your Right to an Accounting of Disclosures. You have
the right to request an "accounting of disclosures." This is a
list of certain disclosures we made of medical information
about you. Your request must state a time period. We may
limit the time period to 6 years and to disclosures made on
or after April 14, 2003. The first list you request within a
12-month period is free. For additional lists, we may charge
you for the costs of providing the list.
Your Right to Request Restrictions. You have the right
to request a restriction or limitation on the medical
information we use or disclose about you. For any services
for which you paid out-of-pocket in full, we will honor any
request you make to restrict information about those
services from your health plan, provided that such release is
not necessary for your treatment.
In all other circumstances, we are not required by law to
agree to your request. If we do agree, we will comply with
your request unless the information is needed to provide
you emergency treatment.
Your Right to Request Confidential Communications. You have the right to request that we communicate
with you about medical matters in a certain way or at a
certain location. For example, you can ask that we only
contact you at work or by mail. If we maintain medical
information about you in electronic format, you also have
the right to obtain a copy of such information In electronic
format and to direct us to transmit such information directly to an entity or person clearly, conspicuously, and specifically designated by you. We will not ask you the reason for
your request. You may make this request in writing or
verbally.
Right to Paper Copy of this Notice. Your have the right
to a paper copy of this Notice. You may ask us to give you
a copy of this Notice at any time.
Right to File a Complaint. If you believe your privacy
rights have been violated, you may file a complaint with us.
You may also file a complaint directly with the Secretary of
the Department of Health and Human Services. You will not
be penalized in any way for filing a complaint.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the
right to make the revised or changed Notice effective for
medical information we already have about you as well as
any information we receive in the future. We will post a
copy of the current Notice at our offices and make copies
available upon request.
PRIVACY NOTICE CONTACT INFORMATION
For questions about this Privacy Notice, contact:
1745 Old Spring House Lane 440
Atlanta GA 30338
Phone: 470-545-1806
Fax: 470-545-1964
ACKNOWLEDGMENT OF RECEIPT OF
“NOTICE OF PRIVACY PRACTICES”
ACKNOWLEDGMENT OF RECEIPT OF “NOTICE OF PRIVACY PRACTICES”
 I hereby acknowledge that I have received a copy of the Prestige Urgent Care Providers’ “Notice of Privacy Practices.”
Print Name of Patient
Signature of Patient or Patient’s Authorized Representative
Date
Time
As the Patient’s Authorized Representative, my relationship with the Patient is:
The Patient is unable to sign because:
–––––– OR ––––––
CERTIFICATION OF GOOD FAITH EFFORTS TO OBTAIN ACKNOWLEDGMENT

I hereby certify that, as an employee or agent of the Prestige Urgent Care Providers, I have made a good faith
effort to obtain from the patient or the patient’s authorized representative a written acknowledgment of the
Prestige Urgent Care Providers’ “Notice of Privacy Practices” in accordance with the policy titled “Provision of
the Notice of Privacy Practices.”
Print Name of Employee/Agent and Department
Signature of Employee/Agent
Reason(s) For Not Obtaining Acknowledgment:
126370P Rev. 04/14
Date
Time