CAPlTAL REGIONAL MEDICAL GROUP

2770 Capital Medical Blvd, Suite200 Tallahassee, FL 32808 • Phone 850-878-8235 • Fax 850 219-2347

Welcome to Capital Regional Medical Group

We look forward to your upcoming appointment. Enclosed are the new patient documents needed for

your visit. Please take the time to fill them out prior to your appointment. Arrive 15 minutes early with the COMPLETED documents along with your current health insurance card and photo ID. It is vital that each section is correctly filled out to prevent delays at check-in.

Please list the name and location of the pharmacy that you use and all medications you are currently

taking along with the dosage.

If you have any questions, please do not hesitate to call our office.

Sincerely,

Capital Regional Medical Group

CAPITAL REGIONAL MEDICAL GROUP

Patient Demographics Name:------------- ----- Date of Birth: ____________Age: _______

Address:------------ ---- - ---City, State Zip:-----------------­

Home Phone: _ ________ Work Phone: _________ Cell Phone:------ ------­

Social Security#: _____-______-______ Email:---------- ------- --­

Sex: (Ci rcle one) Male Female

Employment Status: D Full-Time D Part-Time D Not-Employed D Retir~d

Employer:-- -------------­

Marita l Status: 0 Married O Single O Widowed D Divorced 0 Legally Separated

Race: 0 Native American 0 Asian 0 Native Hawaiian or other Pacific Islander D African American

O White O Hispanic or Latino

Language of Choice:-- - ------------­

Emergency Information

Emergency Contact Name:---------- - -----Relationship:-- - -----------­

Emergency Contact Home Phone:--- -----------Cell Phone: - -------------- ­

Physician and Pharmacy Information Referring Physician: _____ _ ______ _ ___ Primary Physician: _________________

Pharmacy Name: ___________Address: _ _____________Phone #: ________

Primary Insurance Information

Name of Primary Insurance: ------ ------ - --- Insurance ID#:--------------­

Subscriber's Name: ___________________Group#:----------------­

Subscribers' Date of Birth:___ ____ _ ______ Co-Pay$: _ _______ Prescription Plan: YES NO

Secondary Insurance Information Name of Secondary Insurance: _____________ __ Insurance ID#:--------------­

Subscriber's Name: ______________ ____ _ Group#:------ ----------­

Subscribers' Date of Birth: _ _____________Co-Pay$: _ _______ Prescription Plan: YES NO

Patient(orResponsible Party) Signature: _ _ ____ ________ _ _ ___ _ _________

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CAPITAL REGIONAL MEDICAL GROUP

Patient Consent Form Please Read and Sign

I, the undersigned, hereby consent to the following treatment:

• Administration and performance of all treatments • Administration of any needed anesthetics • Performance of such procedures as may be deemed necessary and advisable in the treatment of this patient • Use of prescribed medication • Performance of diagnostic procedures I tests and cultures • Performance of other medically accepted laboratory tests that may be considered medically necessary or

advisable based on the judgement of the attending physician or their assigned designees

I fully understand that this is given in advance of any specific diagnosis or treatment.

I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment

recommended. The consent will remain in full force until revoked in writing.

I understand that Capital Regional Health may include consent at satellite offices under common ownership.

I, the undersigned, authorize Capital Regional Health Care physicians to use and disclose my information for the

purpose of treatment, payment and healthcare operations as described in the Notice of Privacy Practices.

A photocopy of this consent shall be considered as valid as the original.

MEDICARE PATIENTS: I authorize to release medical information about me to the Social Security

Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to

Capital Regional Health Care.

I acknowledge that I have been given the Capital Regional Health Care Notice of Privacy Practices. I

understand that if I have questions or complaints that I should contact the Privacy Official. Patient

Initial:

I certify that I have read and fully understand the above statements and consent fully and voluntarily

to its contents.

Patient (or Responsible Party) Signature Date

CAPITAL REGIONAL MEDICAL GROUP

NO SHOW POLICY

Missed appointments constrain our ability to care for your health needs, and the

needs of other patients who could have been seen in the time set aside for you.

If you do not show up for your appointment and do not call, you may be

discharged from this practice.

If you must cancel an appointment, please be considerate and call at least 24

hours in advance.

Patient Name:----------------- ­

Patient Signature:---------------- ­

Date: _________

2770 Capital Medical Blvd, Suite 200 •Tallahassee, FL 32308 • Phone 850-878-8235 • Fax 850-219-2347

- -CAPITAL REGIONAL MEDICAL GROUP

NEW PATIENT PACKET

Patient Medications

Insu rance _____________________ Email ________________

ALL NEW PATIENTS MUST HAVE PRIOR MEDICAL RECORDS

CRMG PROVIDERS DO NOT PRESCRIBE LONG TERM PAIN M EDS:

Medication refill requests made through yo ur pharmacy will be addressed as soon as possible. Please allow a processing time of 3 days for your pharmacy to receive approval of your medications. In the event your pharmacy does not have your medications refilled after this period of time, please contact our office and we will be happy to assist you.

Please list ALL MEDICATIONS you are actually taking, including over the counter drugs, such as vitamins, aspirin, etc.

Medications Dosage/Frequency Refills (circle)

y N

y N

y N

y N

y N

y N

y N

y N

y N

y N

Pharmacy Name: ----------------- Location: -------------- - ­Phone: ___________________ ~

Lab Results

Un less otherwise directed by your physician, you will be notified within 2 weeks of your results.

Any critical or abnormal results wi ll be communicated to you immediately by your Provider team.

Today's Date Patient Name DOB

- -CAPITAL REGIONAL

MEDICAL GROUP

NEW PATIENT PACKET MEDICAL HISTORY RECORD

All information is treated as confident ial unless you grant permission to release it. PLEASE PRINT AND COMPLETE ALL INFORMATION.

Please answer the following guestions: y N Have you recently had 12ain in the stomach which: y N Do you frequently have severe headaches? D D Occurs 1-2 hours after a meal? D D (If yes, answer the following) D D Is brought on by eating fried foods, gassy foods? D D Do they cause visual trouble? 0 0 Awakens you at night? 0 0 Do they occur on one side of the head? 0 0 Is relieved by antacid medications? D 0 Do they awaken you at night from sleep? 0 0 Is relieved with milk or eating? 0 0 Do they feel like a tight hat band? D D Occurs while eating or immediately after? D D Do they hurt most in the back of the head and neck? D D Is relieved by a bowl movement? 0 0 Does aspirin relieve them? 0 D Causes loss of appetite? D 0 Have you ever fainted? y N Do you freguently have: y N Spells of dizziness? D D Bleeding Gums? D D Spells of weakness of an arm of leg? D D Trouble Swallowing? D D Ringing of ears? D D Hoarseness? D D Have you ever had a convulsion? D D A sore tongue? D D Double Vision? D D Nausea and vomiting? D D Pain in ear(s)? D 0 Nosebleeds? D D Have you ever had shortness of breath? y N Have you had: y N When/Since When During your usual work? D D Burning with urination? D 0 Climbing a flight of stairs? D D Loss of control of bladder? 0 D Which awakens you at night? D D Blood in the urine? D D Do you have achronic cough? D D Dark colored urine? D D Which causes you to cough? D D Trouble starting to urinate? 0 D Accompanied by wheezing? D D Trouble holding the urine? D D Have you ever coughed blood? 0 D To get up frequently at night? D D Do you cough up much sputum? D 0 Passed a kidney stone? D 0 Have you ever had Qain or tightness in the chest which begins:

y N y N When exerting yourself? 0 D Radiates down the arm? D D When walking against a wind? 0 0 Disappears if you rest? D 0 When walking up a hill? D 0 Occurs only at rest? 0 0 After having a heavy meal? 0 D When walking fast? D 0 When upset or excited? D D When walking in cold weather? 0 D Palpations? D D If you have chest pain or tightness please explain: Do you sleep on more than one pillow? 0 D

Have you recently had: y N When/Since When If you've had a change bowl habit recently answer below: Pain in your calves when walking? D D y N When/Since When Craps in legs at night? 0 D Crampy pain in the abdomen? 0 0 Pain in the big toe? D D Alternating diarrhea and constipation? D 0 Varicose veins? D 0 Pain during or after bowl movement? D D Phlebitis or infiamed leg veins? 0 0 Mucous in thestool? 0 0 Swelling in the ankles? D 0 Ribbon-like stools? D 0

Black stools? D D Require the use of strong laxatives D 0 Or enemas? D D

Describe briefly your 12resent medical sym12toms and anything else we should know about your health below.

Capital Medical Blvd., Suite 200 CAPITAL REGJONAL Tallahassee, FL 32308

MEDICAL GROUP NEW PATIENT PACKET- MEDICAL HISTORY RECORD 850.878.8235

All information is treated as confidential unless you grant permission to release it. PLEASE PRINT AND COMPLETE ALL INFORMATION. I

Last Name First Middle ITcday's Date

Birth Date Mate D Female D IMarital Status IOccupation

Home Phone Daytime Phone Preferred Nunber

Last physical Examination By Doctor Phone

What are your present medical symptoms?

FAMILY Living Deceased ANY BLOOD RELATIVES WHO HAVE/HAD ANY OF THE LISTED CONDITONS HISTORY HEALTH

HEALTH Death Death YES NO RELATIONSHIP YES NO RELATIONSHIPAge Good Fair Poor Age Cause

Father Asthma Hay Fever

Mother Arthritis Insanity

Brothers Allergies Kidney Disease Sisters

1.M F Anemia Leukemia

2. M F Alcoholism Migraine

3.M F Bleeding Tend. Nervoos Break ·n

4.M F Cancer Obesity 5.M F Colitis Rheumatism Sons Circle Congenital Heart Rheumatic Fever Daughters Sex

1. M F Diabetes Stroke 2.M F Epilepsy Suicide

3. MF Goiter Stomach Ulcers

4. MF High Blood Pressure Ttberculosis

5. M F Heart Disease

HABITS MEDICATIONS ! ti IF TAKEN}

DO YOU y N DAILY CONSUMPTION Antacids 0 Blood Thinning Pills D Insulin, Diabetic Pills D Thyroid Med D SMOKE DD PKGS Antibiotics 0 Cortisone 0 Iron/Poor Blood Med 0 Tranquilizers 0 DRINK COFFEE ! DD CUPS Aspirin, Bufferin, Anacin D Cough Medicine D Laxatives D Vitamins D DRINK ALCOHOL DD oz Barbiturates D Digitalis D Phend:Jarbital D WaterPills 0 DRINK BEER DD oz Birth Control Pills D Dilantin D Shots D Weight Reduc. Pills D FALL ASLEEP EASILY DD Blood Pressure Pills D Hormones D Sleeping Pills D Other AWAJKEN EAJRLY DD OE!!lrations }'.OU have had: Year Diseases that reguired hoseitalization: Year Serious Illness ­ no hoseitalization reg: Year

Drugs ~ou are allergic to: Describe an~ serious injuries or accidents ~ou have had:

WOMEN ONLY y N MEN ONLY y N Are }'.OU still haviog r!ll;lular month!}'. ~riods? D D Have you ever had bleedng between your periods? D D When? HAVE YOU EVER HAD: D D Do you have very heavy bleedng with you periods? D D When? Loss of sexual activity? D D Do you feel bloated and irritable before your period? D D If yes, for how long?___ Are you naw on or have youever taken birth control pills? D 0 When? Treatment for genitals? D D Have you ever had amiscarriage? D D When? (private parts) D DHave you ever had discharge from the nwle of your breast? 0 0 When? Discharge from penis? 0 0Do you regularly have the cancer test of the cervix? 0 D Hernia (rupture)? 0 0If yes, Date ofLast Test Prostate Trouble? 0 0 How many children bcrn alive? How many miscarriages? How many stillbirths? How many cesarean operations?__ How many premature births? Any Complication of pregnancy? (explain)

Living Deceased

-------- ----

PATIENT HIPAA ACKNOWLEDGMENT AND

CONSENT FORM Patient Name (Printed): -----------Dateof Birth: ---------­

Notice of Privacy Practice/clinics.

____ (Patient/Representative initials) I acknowledge that I have received the practice/clinic's Notice of Privacy Practice/clinics, which describes the ways in which the practice/clinic may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider's business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice/clinic's Notice of Privacy Practice/clinics.

Disclosures to Friends and/or Family Members

DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM?" I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findinQs and care decisions to the family members and others listed below:

Name Relationship Contact Number 1: 2: t--------------11-------------+--------------~

3: '--------------''-------------'--------------~ Pat1ent/Representat1ve may revoke or modify this specific authorization and that revocation or modification must be in writing.

Consent for Photographing or Other Recording for Security and/or Health Care Operations I consent __ (Patient/Representative Initials) to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice/clinic's health care operations purposes (e.g., quality improvement activities) . I understand that the facility retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law. -OR­/ do not consent __ (Patient/Representative Initials) to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice/clinic's health care operations purposes (e.g., quality improvement activities).

Consent to Email. Cellular Telephone, or Text Usage for Appointment Reminders and Other Healthcare Communications:

We want to stay connected with our patients. Patients in our practice/clinic may be contacted via email, calls to your cellular telephone (including prerecorded/artificial voice messages and/or calls from an automatic dialing device), and/or text messaging to confirm an appointment, to obtain feedback on your experience with our healthcare team, and to be provided general health reminders/information. If at any time, you provide an email, cellular telephone number, address or text number below, you understand that you may get these communications from the Practice/clinic. You may opt out of these communications at any time (see next page).The practice/clinic does not charge for this service, but standard text messaging rates or cellular telephone minutes may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

I authorize to receive text messages and/or cellular telephone calls for appointment reminders, feedback, and general health reminders/information and the cell phone number is ' authorize to receive email messages for appointment reminders and general health reminders/feedback/information and the email that is____ _ ________

-OR­I decline ___ (Patient/ Representative Initials) to receive communication via text. I decline _ __ (Patient/ Representative Initials) to receive communication via cellular telephone call. I decline (Patient/ Representative Initials) to receive communication via email.

Updated· January 2018 v6 replacing_j22Q16.'""',0""'""2216,_........... a15'""'...,,,...J121...,.5,__.._.........._.3________________,4 ............., 1 02..,..........., 06 ........ , 11211...,_A photocopy of t his consent shall be considered as va lid as the original.

[PRACTICE/CLINIC/CLINIC NAME]

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Note: This clinic uses an Electronic Health Record that will update all your demographics and consents to the information that you just provided. Please note this information will also be updated for your convenience to all ouraffiliated clinics that share an electronic health record in which you have a relationship.

Release of Information.

I hereby permit practice/clinic and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations. • Healthcare information regarding a prior service(s) at other HCA affiliated providers may be made available to

subsequent HCA-affiliated providers to coordinate care. Healthcare information may be released to any person or entity liable for payment on the Patient's behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer's designee when the services delivered are related to a claim under worker's compensation.

• If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse's notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary.

• Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS.

[Practice: OPTIONAL ON FORM- REMOVE THIS Prescription Order Pick up Section ONLY i f NA to your practice/clin ic ] Prescription Order Pick-up. There may be times when you need a friend or family member to pick-up a prescription order (script) from your physician's office. In order for us to release a prescription to your family member or friend, we will need to have a record of their name. Prior to release of the script, your designee will need to present valid picture identification and sign for the prescription. • I do want __ (Patient/Representative Initials) to designate the following individual to pick up a

prescription order on my behalf: o Name: Date:-------- ­

o Name: Date:-------- ­• I do not want __ (Patient/ Representative Initials) to designate anyone to pick-up my prescription order.

Patient/Parent/Guardian/Patient Representative Signature--------- Date: ______

Patient/Parent/Guardian/Patient Representative Name (Printed) -------- ­

Patient Name (Printed): Date of Birth:--------- ­

Only Ifyou have previously consented to receive communication via text/cellular telephone ca/I/email and wish to remove the consent/Opt Out/Revocation ofcommunications via email and/or text or cellular telephone call. In other words, I do not want my email address or cell number to be used any longer for the above mentioned communications.

_I hereby revoke my request to receive any future appointment reminders, feedback, and general health via text. _I hereby revoke my request to receive any future appointment reminders, feedback, and general health via cellular telephone call. _I hereby revoke my request to receive any future appointment reminders, feedback, and general health via email.

Patient Name: ------------------------ ­

Patient/Patient Representative Signature: _____________________ Date: Time:

Upda~d· Janua~2018v6~placing 122016~~-~ 15_,_06~ 11_2~1__~~~~~~~~~~~~~~· 10_2_8~ ~12_1~5_,~ 1 3A photocopy of this consent shall be considered as valid as the original.

:OPTIONAL ON FORM- REMOVE THIS Prescription Order Pick up Section ONLY if NA to your practice/clinic]

CAPITAL REGIONAL MEDICAL GROUP

How did you hear about us?

Please check all that apply:

0 Primary Care/ Other Physician 0 Friend/word ofmouth D Internet D Billboard D Radio 0 Seminar 0 Community Outreach Event D Insurance Company 0 Television 0 Other