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NEW PATIENT FORM

We hope you can tell us how you came to make this appointment today. You can check more than one.

Questions or comments?

Name:

Date: Email:

Family PracticeAssociates of Voorhees

PATIENT INFORMATION: Family Practice Assocales of Voorhees

Last Name: First Name: MI:

Mailing Address: Apt #:

City: State: Zip:

Home Phone: Cell Phone: Work Phone:

Social Security #: Date of Birth: Sex: M F Marital Status:

Email address: Preferred method of contact:

Emergency Contact: Relationship:

INSURANCE INFORMATION:

Primary Insurance Name: ID #:

Address: City, State Zip

Subscriber Name: Group #

Subscriber Date of Birth: Patient relationship to subscriber:

Secondary Insurance Name: ID#:

Address: City, State Zip

Subscriber Name: Group #

Subscriber Date of Birth: Patient relationship to subscriber:

RESPONSIBLE PARTY INFORMATION: **(lithe patient is a minor, the parent/guardian bringing the patient will be listed

as the FINANCIALLY responsible party)

I Last Name: First Name:

Date of birth: Social Security #:

Address:

City, State, Zip: Phone #

Relationship to patient:

By signing this form I authorize the release of medical information to my insurer, and assign insurance benefits to Family Practice Associates of Voorhees PA. I agree to accept the fees charged as a legal and lawful debt, and agree to pay said fees, including any/all collection fees, attorney fees, and/or court costs, should it be necessary. Our policy is to charge for missed appointments not canceled within a reasonable amount of time These charges will be your responsibility and billed directly to you Please help us to serve you better by keeping your regularly scheduled appointment.

Signatu

Date:

Print Name:

Family Practice Associates of Voorhees

First Name: _ Last Name: Male / Female

Marital Status:

Today's Date: Address: Date of Birth:

Email: Cell:

Social Security #:

What is the reason for your visit today?

Please check off past medical history: 0 Anxiety 0 Heart Disease

0 Depression 0 Thyroid Problems

0 Asthma 0 Urinary Problems / Kidney Problems

0 Arthritis 0 Diabetes

0 Blood Clots 0 High Cholesterol

0 Bleeding Disorder 0 Back Pain / Problems

0 Cancer, if YES what type: - 0 Migraines

0 Other: 0 High Blood Pressure

0 Heartburn (GERD)

0 COPD / Emphysema

Surgical History (Indicate TYPE and YEAR)

Social History: (Please circle)

Have you ever smoked? Y or N If yes, average number of cigarettes per day? How many years have you smoked If former smoker, when did you quit? Do you drink? Y or N If so, how many drinks per week? Do you use illegal drugs? Do you exercise? Y or N - If yes, how many times per week & what type

Do you wish to be tested for sexual transmitted diseases? Y or N

Do you feel afraid of your partner or living situation? Y or N Do you have a "living will"? Y or N

Page 1

Medication list (include mg and directions)-

Pharmacy (Name, Location, Phone Number):

Local Mail-Order

Any known allergies? (Medications + ANY others):

Preventative Care - (If yes please provide date and details): 0 Colonoscopy 0 Pneumonia Shot

0 PSA 0 Shingles Shot

0 Flu Shot 0 Tetanus shot

0 Mammogram 0 Date of last lab work

0 DEXA Scan

0 Pap smear

List any specialist doctors ** (Doctors name and the reason for the visits, and their locations) **

Is there anything else regarding your health we should know about?

Page 2

Family History:

Mother Father Sister Brother Grandmother Maternal

Grandfather Maternal

Grandmother Paternal

Grandfather Paternal

Heart Disease

Diabetes

Cancer (WHAT TYPE) Stroke

High Blood pressure Kidney Disease

Brain Aneurysm

Blood Clots

Colon Polyps

High cholesterol

Thyroid Disease

Page 3

,

Isio .„, r r 1.

Family Practice Associates of Voorhees

With my consent Family Practice Associates of Voorhees may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Family Practice Associates of Voorhees P.A. Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have been offered a copy of the Notice of Privacy Practices. I have the right to review the Notice of Privacy Practices prior to signing this consent. Family Practice Associates of Voorhees P.A. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notices of Privacy Practices may be obtained by forwarding a written request to us at 805 Cooper Road. Suite 3, Voorhees NJ 08043.

With your consent, Family Practice Associates of Voorhees PA, and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless numbers. We may also contact you via text messages, emails, or leave a message on your answering machine in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including normal (benign) laboratory and radiology results among others. Methods of contact may include pre-recorded/artificial voice messages, and/or use of automatic dialing, as applicable

Complicated or Normal lab results and or radiology results may be discussed with the following family Members

Relationship

Relationship

IF YOU DO NOT GIVE CONSENT PLEASE CHECK ALL BOXES BELOW THAT APPLY:

Do not leave normal (benign) lab and radiology results with family members or on answering machine

Do not discuss any lab results and or radiology results with anyone but the patient or the patient's parent if the patient is a minor.

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by the agreement.

By signing this form I am consenting to Family Practice Associates of Voorhees P.A. use and disclosure of my PHO to carry out TPO. I agree to accept the fees charged as a legal and lawful debt, and agree to pay said fees, including any/all collection fees, attorney fees, and/or court costs, should it be necessary.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Family Practice Associates of Voorhees P.A. may decline to provide treatment to me.

Signature of Patient or Legal Guardian Date

Print Name of Patient or Legal Guardian

01/2018

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

*You may refuse to sign this acknowledgment*

Family Practice Associates of Voorhees, P.A.

have reviewed and or received a copy of this office's Notice of Privacy Practices.

Signature

Date

For Office Use Only

We attempted to obtain acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:

Individual refused to sign

Communication barriers prohibited the acknowledgment

An emergency situation prevented us from obtaining Acknowledgment

Other ( Please Specify)