Douglas C - PatientPop



Dr. Douglas C. Shoenberger, PC

PATIENT INFORMATION SHEET

DEMOGRAPHIC INFORMATION

NAME: DOB:

ADDRESS: HOME #:

CELL #:

EMAIL: WORK #:

SS #:

EMERGENCY CONTACT INFORMATION

NAME: PHONE:

RELATIONSHIP: ALT PHONE:

PHARMACY INFORMATION

PHARMACY NAME: PHONE:

LOCATION:

FINANCIAL POLICY

PAYMENTS/CO-PAYMENTS ARE DUE AT THE TIME OF SERVICE. BILLING OF CO-PAYMENTS WILL BE ACCESSED A $5.00 HANDLING FEE. WE ACCEPT PAYMENT IN THE FORM OF CASH, CHECKS, VISA, AND MASTERCARD.

I GIVE PERMISSION TO DOUGLAS C. SHOENBERGER, M.D./COOPERSBURG FAMILY PRACTICE TO BILL MY INSURANCE COMPANY. I ALSO UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL SERVICES RENDERED. I UNDERSTAND THAT A FINANCE CHARGE OF 1.5% MONTHLY WILL APPLY AFTER 90 DAYS AND A 35% COLLECTION FEE IS ASSESSED TO ALL ACCOUNTS REFERRED TO OUR COLLECTION AGENCY.

SIGNATURE: X DATE:

Copy of Photo I.D. (State I.D./Driver’s License/Passport)

PMR Scanned to EHR: Narcotic Agreement Signed:

Date Date

PATIENT NAME: DATE OF BIRTH:

DRUG ALLERGIES:

MEDICATION LIST:

|MEDICATION |STARTED |D/C |MEDICATION |STARTED |D/C |

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PROBLEM LIST:

|ONSET DATE |PROBLEM |RESOLVED |

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VACCINE ADMINISTRATION RECORD

PATIENT NAME: DATE OF BIRTH:

I have read, or have had explained to me information about the diseases and the vaccine listed below. I believe I understand the benefits and risks of the vaccines, and ask that the vaccine(s) listed below be given to me or to the person named above for whom I am authorized to make this request. By signing below, I understand that if my insurance does not remit payment to Dr. Shoenberger for the vaccines given I will be financially responsible for any unpaid charges.

|VACCINE |DATE GIVEN |LOT NUMBER |NURSE |PARENT SIGNATURE |

|DTP 1 | | | | |

|DTP 2 | | | | |

|DTP 3 | | | | |

|DTP/DTAP 4 | | | | |

|DTP/DTAP 5 | | | | |

|DT/ADACEL | | | | |

|OPV/IPV 1 | | | | |

|OPV/IPV 2 | | | | |

|OPV/IPV 3 | | | | |

|OPV/IPV 4 | | | | |

|MMR 1 | | | | |

|MMR 2 | | | | |

|HIB 1 | | | | |

|HIB 2 | | | | |

|HIB 3 | | | | |

|HIB 4 | | | | |

|HEP B 1 | | | | |

|HEP B 2 | | | | |

|HEP B 3 | | | | |

|VARICELLA 1 | | | | |

|VARICELLA 2 | | | | |

|MENACTRA 1 | | | | |

|MCV (A,C,Y,W) | | | | |

|MENACTRA 2 | | | | |

|MCV (A,C,Y,W) | | | | |

|TRUMENBA 1 | | | | |

|Meningitis B | | | | |

|TRUMENBA 2 | | | | |

|Meningitis B | | | | |

|GARDASIL 1 | | | | |

|GARDASIL 2 | | | | |

|GARDASIL 3 | | | | |

|PREVNAR | | | | |

|PNEUMOVAX | | | | |

|INFLUENZA | | | | | | | |

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|MANTOUX | | | | | | | |

|OTHER | | | | | | | |

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