New Patient Information · (Power of Attorney or Parent/Legal Guardian) Preferred Method of Contact ... Hepatitis ( ) Tuberculosis ( ) Colon Disease ( ) Leg Cramps

Dr. Mickey D. Stapp | Dr. Brian Bennett | Dr. Christopher Anna | Dr. Trevor S. Payne

4350 Towne Centre Drive | Suite 3000 | Evans, GA 30809 |706-312-3668

New Patient Information:

Patient Name: __________________________________________________________________

Date of Birth: ___/___/____ Age: _____SEX: Male or Female SS#___/___/____

Home Address: _________________________________________________________________

City/State: ______________________________ ZIP: __________________

Home # _________________ Cell # _____________________

Email Address ______________________________________

Occupation: _______________________________________Work # __________________

Primary Language: ______________________ Ethnicity: ________________

Guarantor Name: ______________________________________Date of Birth: ___________ (Power of Attorney or Parent/Legal Guardian)

Preferred Method of Contact (Circle All That Apply)*: Home Phone Cell Phone Email *Text and Data rates may apply - used for our purposes only

Primary Care Physician Name: ____________________________________________________

Last PCP visit ____________ Phone # ______________________________

Pharmacy Name: _________________________Location: _______________

Pharmacy # ___________________________________________________________________

Insurance Information:

Primary Insurance Name: ________________________________________________________

ID# __________________________________GRP# _______________________

Secondary Insurance Name: ______________________________________________________

ID# ______________________________GRP # _________________________

Who referred you to our office or how did you hear about us:

_____________________________________________________________________________________

Dr. Mickey D. Stapp | Dr. Brian Bennett | Dr. Christopher Anna | Dr. Trevor S. Payne 4350 Towne Centre Drive | Suite 3000 | Evans, GA 30809 |706-312-3668

Reason for your visit today: ____________________________________________________________

Shoe Size: __________ Weight: __________ Height: __________

Social History:

Tobacco Use ( ) Never ( ) Former ( ) Occasionally ( ) Daily packs/# Per day _________

Alcohol Use ( ) Never ( ) Occasionally ( ) Daily Drinks/Day __________

Patient History:

Allergies: _____________________________________________________________________________

Medication Allergies: ___________________________________________________________________

Other: _______________________________________________________________________________

Family Health History: ___________________________________________________________

______________________________________________________________________________

Please List ALL MEDICATIONS you are currently taking (including prescribed, over-the-counter,

and herbal/nutritional supplements) or PLEASE PROVIDE A LIST

Name: Dose Frequency

Do you have or have you ever had any of the following? Please ALL that applies

( ) Acid Reflux ( ) High Blood Pressure ( ) Fibromyalgia ( ) Arthritis

( ) Asthma ( ) High Cholesterol ( ) Abnormal Bleeding ( ) Back Trouble

( ) Cancer ( ) Rheumatic fever ( ) Pneumonia ( ) Blurred/Double Vision

( ) Diabetes ( ) Seizures ( ) Bladder Infection ( ) Anemia

( ) Gout ( ) Stomach Ulcers ( ) Chest pain/Angina ( ) Blood Clots

( ) Heart Attack ( ) Stroke ( ) Mitral valve Prolapse ( ) Gallbladder Disease

( ) Heart Disease ( ) Thyroid Disease ( ) Kidney Disease ( ) Vein Disease

( ) Hepatitis ( ) Tuberculosis ( ) Colon Disease ( ) Leg Cramps

( ) HIV/AIDS ( ) Liver Disease ( ) Difficulty Breathing

Please List any other Health Conditions: ____________________________________________________

_____________________________________________________________________________________

Please List All Prior Surgeries: _______________________________________________________

_____________________________________________________________________________

Date ____/_____/____ Signature ___________________________________________



Privacy Practices

Appointment Reminders

As a service to our patients, we contact via your preferred method to remind you of your upcoming appointment. We do not discuss nor release any other information except that you have an appointment in our office at a certain day/time.

(Please Circle) A. May we contact you to remind you of your appointment? YES No

B. If there is no answer at your preferred number, may we leave a voicemail? YES No

C. If you are not available, may we leave this message with the person that answers? YES No

Discussion of your Protected Health Information

By law, we are not allowed to discuss your protected health information with anyone else. Is there

anyone with whom we may discuss your protected health information?

(Please Circle) A. NO You may only discuss my protected information with me (patient).

B. YES You may discuss my protected health information with the following people only:

I. Spouse _____________________________

II. Other ______________________________

Acknowledgement of Receipt of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (have

had the opportunity to read/or have had read to me) and understand the Notice. I understand that I can

rescind or revise my privacy choices at any time.

______________________________________ __________________ Patient Name (Please Print) Date

______________________________________ _____________________________________ Signature Signature of Parent or Guardian/POA





Documents

New Patient Information · (Power of Attorney or Parent/Legal Guardian) Preferred Method of Contact ... Hepatitis ( ) Tuberculosis ( ) Colon Disease ( ) Leg Cramps