Home - West Georgia Center For Diabetes & Endocrinology



Full Name:DOB:SS Number:Address:City:State:Zip:Check primary contactHome Phone:____ Cell Phone:____Work Phone:___Marital Status: Circle One Married Single Divorced Separated Widowed Life Partner Gender Identification: Circle One Male Female FTM MTF Genderqueer Other(specify) Not Disclosed Sexual Orientation: Circle One Straight Gay/Lesbian Bisexual Other(specify) Unknown Not DisclosedRace: Circle One Asian Black Hawaiian/Pacific Islander Native American White MixedEthnicity: Circle One Hispanic Non -Hispanic Occupation: Primary Care Provider: Referring Provider:Emergency Contact Relationship:Name:Contact Phone:Insurance InformationPrimary:Group #:Policy #:Policy Holder: Birthday:Address:Secondary:Group #:Policy #:PharmacyPreferred:Secondary:I hereby authorize and consent for Medical services and authorize to release information required for processing insurance claims and benefits paid directly to the Practice._____________________________________ _______________________ Patient’s signature DateREVIEW OF SYSTEMS Patient’s Name:______________________________DOB:_________________NYNYNYGENERALShortness of breathBREASTRecent weight gainWheezingNipple dischargeRecent weight lossAsthmaNEUROLOGICALFeverGASTROINTESTINALHeadachesFatigueLoss of appetiteDizzinessSweatConstipationSeizuresHeat intoleranceNauseaStrokeCold intoleranceVomitingMemory lossEYES & VISIONDiarrheaPSYCHIATRICEye disease/injuryAbdominal painNervousnessCataractBlood in stoolDepressionGlaucomaGENITOURINARYLoss of concentrationBlurred visionWaking up at night to urinateSleep problemsDouble visionFrequent urinationHEMATOLOGICLast Eye exam date:__________Burning urinationCuts slow to healEAR,NOSE,THROATBlood in urineBruise easilyHearing lossIncontinence/urine leakageAnemicRinging in earSexual dysfunctionSwollen Lymph nodesEar pain or dischargeMUSCULOSKELETALRecurring infectionsSinus problemsJoint painIMMUNOLOGICNose bleedsJoint stiffness/swellingHay feverCARDIOVASCULARDifficulty walkingHivesChest painMuscle painHistory of HIV/AidsShortness of breathWeakness of muscleENDOCRINEHeart racingBroken bonesExcessive thirstSudden loss of consciousnessINTEGUMENTARYUnexpected changein skin colorSwelling of feet/ankles/handRashes/itchesHeat/cold intoleranceRESPIRATORYNew moles/lesionsDry skinChronic coughSudden hair lossCoughing bloodThin brittle nailsPatient’s Name:__________________________________ DOB:__________________________Past Medical History: Please mark if you have been treated to any of the following illnesses.AsthmaHeart attackPituitary diseaseAnemiaHeart DiseaseSeizuresAdrenal DiseaseHigh Blood PressureSexual problemsCancer Type:_______________High CholesterolStrokeCOPDKidney DiseaseThyroid diseaseDepression/AnxietyLiver disease UlcersDiabetesOsteoporosisVision problemsPlease list past surgeries:Allergies & Reactions: Please list ALL allergies (Include adverse reactions to any medications)SOCIAL HISTORY: Tobacco use: Current:__ Past:___(When did you quit:______) Type: Cigarettes/cigars/Chewing How many/ day_____ How many years:_____Alcohol Use: Never: ________ Rarely: ______ Daily:_________ number of drinks/week____________Recreational Drug Use: No:_____ Yes:______ Type & How much?_____________________________Caffeine use (Coffee, Tea, soft drinks: No: _____ Yes:_______ How many/day?____________________Exercise: Do you exercise regularly? ___________ What type & how often?________________________Are you on a diet? No:________ Yes:_________ How long?____________________________________FAMILY HISTORY: Mark the blood relatives who had the following diseases:DISEASEMotherFatherBrother (s)Sister(s)CancerDiabetesHeart DiseaseHigh Blood PressureHigh CholesterolPituitary DiseaseThyroid DiseaseStrokeThank you for choosing us as your healthcare provider. A clear understanding of our policies will help us to build a successful relationship. INSURANCE:We participate with several insurance plans. Please verify your insurance information with the office and your insurance company prior to making the appointment.You should be familiar with your insurer’s requirements such as referrals, pre approvals, deductibles, co-pays and the medications covered by your insurance.We will verify your insurance status at each visit. You are responsible to let us know if your insurance plans have changed.As a courtesy, we will directly bill your primary and secondary insurance providers. You are responsible for all payments that are not covered.PAYMENT:Payment is expected at the time of service. Payment includes deductibles, co-insurance, co-pays and non- covered charges. You will be asked to reschedule if you do not have your co-pay or if you have a delinquent account. Self- pay patients must pay in full at the time of the service.We accept cash, check or credit card Payments are expected within the due date specified in the monthly statements. ADDITIONAL CHARGES AND INFORMATION:Returned checks will incur a $25 feeWe require a 24 hour notice for appointment cancellation. A $25 fee will be applied for missed appointments without notification or appointments cancelled the same day.There is a fee for copying Medical records. A fee up to $25 may be charged based on the number of pages. A summary of care is provided after each visit free of charge.There is a fee of $15 for the Provider to fill out forms and write letters. A fee of $15 per medication will be applied to any Patient Assistance Forms. Access to electronic medical records is available through secure connection. All delinquent accounts will be sent to a collection agency. You will be responsible for the collection agency fees.Medication refill requests should be completed at the time of the office visit with the Provider, do not wait until you are checking out to refill medications. If a refill is required, please request it through the pharmacy and it will be provided with in 24-48 hours. There is no charge for this service. Please note that if the patient has not been seen by the Provider recently, we do not issue refills. APPROVAL: I have read the above payment and attached privacy policies and agree to them.Patient’s signature Date ................
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