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Patient Information

 

For new patients or to update your file:
Please fill out this form and then go to the
Appointments section to request an appointment.

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New Patient           Current Patient   Please update my current information

First Name: * MI:   Last Name: *

Address: *

Suite/Apt #

City: *   State:    Zip Code: *  

Birthday:  / / *                  SSN: *

Contact Number:  *

Cell  Phone Number:  

Work Number: 

E-Mail Address: *


Marital Status:

Spouse's Name:

Do you have children? Yes No How many?

Referred by:

Employer:

Occupation:

Preferred Pharmacy: 

***For your convenience your prescriptions can be faxed if you provide us with the pharmacy.***



Describe the reason for your visit:


What medications do you take: (List medications, dose, frequency)

Do you now have or have you ever had any of the following:

Allergies

Hypertension

Alcohol / drug abuse

Liver disease

Frequent neck pain

Heart attack

Headaches

Fainting/seizures/epilepsy

Diabetes

Low back problems

Heart murmur

STD

Anxiety/Depression

Kidney problems

Sinus problems

Asthma/Respiratory problems

Artificial bones / joints

Pregnant

Menstrual irregularities

Hepatitis 

Cancer

Blood disorders

Ulcers / Colitis

Arthritis

List Past Medical History, Surgery, Hospitalizations:

 

Contact:

Relationship to you:

Home phone # Work phone #:

 

Person ultimately responsible for your account:  To expedite your visit please send us your updated insurance information so that we can pre-certify your visit.

Same as above:  

First Name:  MI:   Last Name:   Sex: 

Address:        City:    State: 

Birthday:  / /


Health Insurance Name: * Other Insurance:

Insurance ID #: *   Group #:    SSN: *

Relationship to you: *  

Insurance Billing address:

PO Box: *

City: *   State:    Zip Code: *  

Phone Number:    

If a required field does not apply to you put none.


I understand that all charges (including those not paid by insurance), collection fee, bank/returned check fees, legal fees and failure to keep appointment fees are the financial responsibility of the patient (or the parent/guardian in the case of a minor). I hereby authorize Dr. Schweinshaupt to release all information concerning my illness (es) and treatments to my insurance carriers/health plans. In the event that Dr. Schweinshaupt participates with my insurance carrier/health plan, I hereby assign all available benefits and payments directly to him for medical services rendered. I understand that I am financially responsible for all balances not covered by my insurance carrier/health plan, and authorize Dr. Schweinshaupt to charge my credit card for the full amount of any unpaid balances.  I acknowledge notification of the privacy practice act.

 

             

* denotes required field

 
     
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