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 | | | | | | | |
| | | | | | | | |
|MANTOUX | | | | | | | |
|OTHER | | | | | | | |
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