ACCOUNT:
PATIENT’S NAME:
DATE OF BIRTH:
AGE:
PATIENT’S EMAIL ADDRESS:
PATIENT’S PREFERRED PHONE NUMBER:
MALE
FEMALE
REASON FOR VISIT:
RESULT OF AN INJURY:
WORK RELATED:
YES
AUTO ACCIDENT:
YES
NO
NO
OTHER LIABILITY:
YES
NO
IF INJURY, BRIEFLY DESCRIBE DETAILS OF HOW INJURY OCCURRED:
YES
NO
STATE WHERE INJURY OCCURRED:
DATE OF INJURY/ONSET:
PHYSICIAN REQUESTING CONSULTATION:
REQUESTING PHYSICIAN’S ADDRESS:
PRIMARY CARE PHYSICIAN:
SEND REPORT:
YES
PHONE: _____________________________
NO
FAX: ________________________________
PRIMARY CARE PHYSICIAN’S ADDRESS:
OCCUPATION:
EMPLOYER:
ALLERGIES:
ARE YOU
ALLERGIC TO
LATEX:
ARE YOU:
MEDICATIONS: LIST CURRENT MEDICATIONS
YES
NO
RIGHT HANDED
LEFT HANDED
CIRCLE AREA(S) OF INJURY OR
ILLNESS ON DIAGRAM
MEDICAL CONDITIONS: ✓ FOR YES
HEART DISEASE
GI DISORDER
HEPATITIS
HIGH BLOOD PRESSURE
REFLUX
HIV
IRREGULAR HEART BEAT
GU DISORDER
TUBERCULOSIS
PACEMAKER
DIABETES
LYME DISEASE
BLOOD CLOTS
THYROID DISEASE
ARTHRITIS
BLOOD THINNERS
CANCER
GOUT
SLEEP APNEA
ANXIETY DISORDER
OSTEOPOROSIS
LUNG DISEASE
DEPRESSION
NEUROLOGIC DISORDER
SURGERIES:
FAMILY HISTORY – LIST ANY MEDICAL CONDITIONS OF IMMEDIATE FAMILY:
SOCIAL HISTORY:
DO YOU SMOKE?
YES
HOW MUCH ________
NO
EMERGENCY CONTACT:
DO YOU DRINK
ALCOHOL?
YES
NO
NAME:
HOW MUCH ________
DO YOU
EXERCISE?
YES
NO
CONTACT #:
RELATIONSHIP TO PATIENT:
SIGNATURE: _____________________________________________________________________________________
GCHS-(09/14)
DATE: ______________________________________
PATIENT NAME: ________________________________PATIENT #:___________
ASSIGNMENT OF BENEFITS:
I hereby authorize the physicians and staff of Greater
Chesapeake Hand Specialists to render services to me or my dependents. I further
authorize Greater Chesapeake Hand Specialists to release my personal health information
for purposes of treatment, payment or operations by phone, mail, or fax. I assign and
authorize payment of medical or surgical benefits directly to GCHS.
FINANCIAL POLICY:
•
•
•
I understand that any unpaid balances or non-covered balances will be my responsibility.
Co-pays are due at the time of service.
In the event my account is referred to an attorney or agency for collections I may be held
responsible for reasonable attorney fees and court costs.
CONTACT INFORMATION:
All contact information obtained from a patient may be used for the purposes of courtesy
pre-recorded calls, email or text messages for appointment reminders.
By my signature, I acknowledge that I have read and understand the above referenced
information. If the patient is a minor, the responsible party is required to sign below.
Signature: __________________________________________Date: _________________
Printed Name – Patient or Responsible Party: _____________________________________
Relationship to Patient (if other than patient):_____________________________________