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NORTHEAST MISS看SSIPPI HEALTH CARE, lNC.
PATIENT RたGISTRAT10N FORM
Patient
しast Name
Address (Street, Citv, State, Zip, County〉
First Name
CHART #
MI
Areyou ofしatino/Hispanic Descent? ( )YES ( 〉 NO
Date of B而h
Sociai Security #
Home Phone
Provider of Choice?
Preferred Language ( ) ENGLISH ( ) SPANISH
Special Communication Needs?
Ema=
Ce= Phone
MARITAしSTATUS: □ Singie □ Married ロWidowed 口Divorced
ETHNIC晴Y:(CheckailthatappIy) 口Asian 口NativeAmerican 口White 口Hispanic/しatino
口Black/AfricanAmerican 口AmericanIndian/AlaskaNative
□OtherPacificIslander 口Morethanonerace
lNCASEOFEMERGENCY,WHOSHOUしDBENOTiFiED?
NAME NAME
REしA丁IONSHIP RELATIONSHIP
pHONE# PHONE#
AUTHORIZATION FOR HEA町H CARE
l. 1 give permission to the Medica- Denta- Providers at NEMHC′ inc. to render care to me orthose forwhom l am
responsible as the P「ovider advises as necessary in the case of any emergency.
2. 1 hereby authorize NEMHC′血・ tO furnish such professiona冊ormation as necessary f「om my medicaI or dental
records compi-ed by NEMHC′ lnc.′ inc-uding professiona- services′ and hereby release NEMHC′ lnc. from aIi
liab冊y that may arise from the release ofthe information requested.
3. I/we agree to ACCEPT COMPLETE RESPONSIBILITY for a-1 charges based on ab冊y to pay and agree to pay the
same at the time services are rendered or no -ater than 90 days from the date of service o「 according to specified
payment (non-COVered Medicare′ Medicaid′ Private insurance charges). 1n the event of default l agree to pay aii
costs of co=ection, including reasonable attomey fees.
4. 1 agree that I have read and understand the above consent and w川accept its terms・
SIGNATURE OF PATiENT/RESPONS旧しE PARTY
1
PATIENT REGISTRATION FORM PAGE 2
DoyoucurrentlvhaveandAdvancedDirectiveorしivingW冊 YESロ NO□
DovouhaveaMedicalPowerofAttomey? YES□ NO□
Wouidbeinterestedintalkingtosomeoneaboutoneofthese? YES口 NO 口
AreyouaVeteran? YES口 NO口
Doyou 口iiveonyourown □Iivewithparents 口Other
A「eyouhomeIess? YES口 NO□
Doyou「esideinPubIichousing(Section8)? YES□ NO口
Since NEMHC, inc. is a Federally Qua嗣ed Heaith Center, We are requi「ed to col○ect this information for FederaI
reporting purposes.
pし各AS各 CH日CK oN日 �SEXUAしORIENTATION �PしたAS各 C軸且CK ONさ �GENDERIDENTITY
STRAiGHT/H打EROSEXUAL � �MAし各
GAY/LESBIAN/HOMOSEXUAL � �FEMAしE
BISEXUAし � �FEMAしETOMALETRANSGENDER
CHOOSENOTTODISCLOSE � �MALETOFEMALETRANSGENDER
DON′TKNOW � �CHOOSENOTTODISCしOSE
OTHER-PLEASESPECIFY � �
EMPしOYMENT INFORMATION
Patient’s EmpIoyer
EmpIoyer Phone ♯
1NSURANCE INFORMATION
DOYOUHAVEMEDICALINSURANCE? 口YES 口NO
PRIMARY INSURER:
NAME OF INSURED:
lD NUMBER:
GROUP ♯:
MEDICARE ♯:
MEDiCAiD ♯:
Empioyer Address
Posjtion:
SECONDARY INSURER
NAME OF INSURED:
ID NUMBER:
GROUP韓:
PARTAONしY口 PARTB □ PARTD口
器器葦器嵩諾器謹書書誌誓書黒結盟柴。。-a- S。叫Administration, the Medicaid Commission′ the Centers for Medicare and Medicaid′ Or any Other third partv payor′ Or
their intermediaries, Or Carriers, needed forthis or a related claim・ l permit a copy ofthis authorization to be used in
place ofthe original′ and request payment of medical claims be made to this clinic"
2
ASSiGNMENT AUTHORIZATION §lGNATURE
PATIENT NAME
lVIEDIcAL HISTORY
AIthough dental personnei prlmarty t'eat the anea in and around your mouth- yOu「 mOuth is a part of you「 entire body. Heam叩bIems that you may
have・ Or medica(ion tha( you may be taking・ ∞uId have an impomnt inter胸ationship with the dentist「y you wilI re∞ive・ Thank you fo「 answering the
fo"owing questions,
Are you under a physicIan-s caro now?
Have you ever been hospitaIized or had a major opemtion?
Have you ever had a serious head o「 nec injury?
Are you faking any medications, PiiIs, O「 d田gS?
Do you take, Or have you taken, Phen-Fen or Redux?
Have岩盤霊言語罵轟詳器労O
Are you on a speclaI die(? ODo you use tobac∞? O
Do you u§e ∞ntroIled substan∞S? ○
If yes. please explain:
If yes, Please exかain:
PregnantITrying to get pregnant?O Yes O No T8king oraI ∞ntra∞Ptives?O Yes O No Nursing? O YesO No
Are you alIergic to any o( the fctIowing?
口Aspirin 口PeniciIiin □codeine □」ocaIAnesthetics 口AcryIic □Mefal 口しatex 口Su胎dngs
口Other tryes, Please explaln:
Do you have, Or have you hadi any oI the foiIowing?
AIDS/HIV Positive O Yes O NoAkheimer’s Disease O Yes O No
AmphylaxIS O Yes O NoAncmia O Yes O NoAngina O Yes O NoArthritis/Goul O Yes O NoA請ficial Heart Vaive O Yes O No
ArtificiaI Joint O Yes O NoAsthma O Yes O NoBIood Disease O Yes O No馴ood T調nsfl」Sion O Yes O No
Broathin9 Probk)m O Yes O NoBnJiso EasiIy O Yes O NoCan∞l O Yes O No
Chemotherapy O Yes O NoChest Pains O Ye5 0 NoCold Soros/Fev○○ Blisl○○s O Yes O No
COnge面tal Heart Disorde○○ Yes O No
ConvuIsions O Yes O No
Cortisone Medicine O Yos O NoDiabol∞ O Yes O No
DnJ9Addic的n O Yes O No
EasilyWindod O Yes O NoEmphyse請a O Yes O No
EpitopsyorSeizuns O Yes O NoExcoesive B劇高調 O Yes O No
Ex∞SSive Thi鴫t O Yes O No
F8intho SpoIIs/Dizz面essO Yes O No
Froquent Cough O Yes O NoFroquent Dia巾1Oa O Ye8 0 No
Froquen…cadaches O Yes O No
GenitalH叩es O Yes O No
GIau∞ma O Yes O No
Hay Feve「 O Yes O No
Heart Attack作ailuro O Yes O No
Hearl Mumu○ ○ Yes O No
H∞rl Pさ∞mのke「 O Yes O No
He8rt TroubIeIDiseaco O Yes O No
Have you ever had any serious illness not listed al)oVe?O Yes O No
Hemop刷ia
Hepa償is A
Hep8償is B or C
H○○pes
Hieh BIood Proesu鳩
HゆChok)S(erOI
Hives oI Rash
H押o9りcemia
I○○eguかHeartboal
櫛dney P∞b鴫同e
Leukemia
しiver Disease
Low Bk)Od P富essure
Lung DIsease
Mi(調i Vaive Prolapse
°s(eopo職場is
Pain in Jaw Joints
P8剛hy両d Disease
Psychiatric Caro
Radiation Treaments
Re∞n! WeiehtしOSS
ReIlal Dialysis
Rheumatic Fever
Rheumatism
Sca巾ot Fev○○
Tothebestofmyknowledge.thequestionsonthisfomhavebeena∞uratelyanswered.1unde「Standthatprovidingincorrectinfomationcanbe
dangeroustomy(0「Patient’§)heam.旧SmyreSpOnS酬ftyt面青くOmthedentaIo簡∞ofanychangesinmedicaistatus.
SiGNATUR∈OFPATIENT,PARENT,O「GUARDIAN DATE
〇〇〇〇〇
NoNoNoNoNo No NoNoNo
〇〇〇〇〇〇〇〇〇
YeS海S汚SYeS海S准S 汚S汚SYeS
博冊N。N。N。N。N。N。N。N。N。N。N。N。N。的N。NoN。
○○〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇
滴洛深海篭深海s悔汚s汚S窪Y・SYeS‰
〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇○○
N。的N。時N。N。N。N。N。N。N。N。N。N。的N。N。N 。No的
〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇○○
庵悔沈S性。汚S汚S汚。YeSYeS汚S悔順庵庵治悔悔YeSY・S
〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇○○