Patient Registration Form

Today's Date:

PCP:

PATIENT INFORMATION

Patient's Last Name:

First Name:

Middle Name:

Marital Status (Circle One): Single Div Sep Wid

Email Address:

Date of Birth:

Age:

Sex: M F

Street Address:

Social Security Number:

Home Phone No:

City:

State:

Zip Code:

Cell Phone No:

Occupation:

Employer:

Employer Phone No:

Preferred Language(s): English Spanish

Other

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race: American Indian or Alaska Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White

Gender Identity: Male Female Transgender Male Transgender Female
Genderqueer Other Decline to Answer

Sexuality: Heterosexual Homosexual Bisexual

Dont Know Decline to Answer

Something else

INSURANCE INFORMATION

(Please give your insurance card to the receptionist.)

Name of Primary Insurance:

Policy Holder Name:

Policy Holder S.S. #:

Date of Birth:

Group #:

Policy #:

Patient's Relations to Subscriber: Self Spouse Child Other

Employer:

Employer Address:

Employer Phone #:

Name of Secondary Insurance (If Applicable):

Subscriber's Name:

Group #

Policy #

Patient's Relations to Subscriber: Self Spouse Child Other

I, the undersigned authorize payment of medical benefits to Northstar Surgery Specialists, P.A. for any services furnished me by the physician.” To “I, the undersigned, authorize payment of medical benefits to NorthStar Surgery Specialists, P.A. for any services furnished to me by the physician. I understand that I am financially responsible for any amount not covered by my contract. I also authorize you to release to my insurance company or their agent information concerning health care, advice, treatment or supplies provided by me.” To “I also authorize NorthStar Surgery Specialists to release information concerning my health care, advice, treatment or supplies provided to me to my insurance company.

Parent/Guardian Signature:

Date:

ADDITIONAL INFORMATION

1. In case of an Emergency, Please Notify :

Name:

Phone Number:

Relationship to Patient:

May we inform this person of confidential information? YES NO

Name:

Phone Number:

Relationship to Patient:

May we inform this person of confidential information? YES NO

2.Can Confitenial Messages be left on you:

Home Telephone Answering Machine: YES NO

Cell Phone VoiceMail: YES NO

Work VoiceMail: YES NO

Personal Email: YES NO

3. Do you have a LIVING WILL? YES NO

4. Do you have a medical Power of Attorney? YES NO

If yes then, Name:

Number

5. Pharmacy Information:

Preferred Pharmacy:

Pharmacy Phone #:

Pharmacy Address:

Acknowledgement of Notice of Privacy Practices & Cancellation Policy

I have reviewed the Notice of Privacy Practices of NorthStar Surgery Specialists, P.A., which explains in plain language how my protected health information (PHI) will be used and disclosed, my individual rights, and the practice’s legal duties with respect to my PHI. I understand that I am entitled to receive a copy of this information upon request.

I also acknowledge the following cancellation/no show policy: New patients that no show to a scheduled appointment are subject to a $50 no show charge. Established/post-operative patients are subject to a cancellation/reschedule/no show charge of $50 if a 24 hour notice is not given, 7 day notice must be given to cancel/reschedule surgery, if 7 day notice is not given, you are subject to a $250 cancellation fee.

Signature:

Date:

Release of Medical Records

I am requesting that the medical information be transferred to Vineet Choudhry MD.
I understand that the information in my or my child’s health record may include information relating to STD, AIDS, or HIV. It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

Signature:

Date:

Medical History Form

Todays Date:

Date of Birth:

Sex: M F

Height:

Weight:

Primary Care Physician:

Referring Physician:

Address

City/State/Zip

Chief Complaint/Purpose of Visit:

Medical History:

Please List all the Current and Past Medical Conditions

None

Heart Disease

COPD/Emphysema/Bronchitis

Other

Previous Heart Attack/Chest Pain

Asthma

Congestive Heart Failure

Other Lung Disease

Heart Valve Disorders

Type

Heart Rhythm Problems

Cancer

High Blood Pressure

High Cholesterol / Lipids

Gall Bladder Disease

History of Stroke

Diabetes

Bowel Disease

Peripheral (Leg) Vascular Disease

Type

Epilepsy / History of Seizures

Hepatitis / Liver Disease

Arthritis

Type

Anemia

Kidney / Bladder Disease

Stomach Ulcer

Clotting / Bleeding Disorder

Thyroid Disease

Type

Please list any pertinent descriptions, if needed, of any above conditions checked:

Surgical History - Please list Previous Operations and the year when they were performed: None

Procedure

Gallbladder (Cholecystectomy)

Coronary Artery Bypass

Thyroid

Appendix (Appendectomy)

Other Heart Surgery

Breast Biopsy/Mastectomy

Hernia Repair (any)

Lung Surgery

Tonsillectomy

Stomach/Bowel Surgery

Joint/Back Surgery

Plastic Surgery

Rectal/Hemorrhoid

Hysterectomy/C-Section

Skin surgery (Mole Removal, Graft, etc.)

Other

Medications- Please list all medications you are taking, including over-the-counter and herbal: None

Allergies- Please list any allergies to medications below: None Latex

Social History:

Maritial Status

Single Married Divorced Widowed

Do you have children? Yes No

How Many?

Ages?

Do you Smoke or Chew Tobacoo: Never Chew Smoke Former Smoker

Pack Per Day:

No of Years:

Have you tried to quit? Yes NO

Date Quit

Do you use illicit drugs? Yes No

Type and Frequency

Do you Drink Alcohol? Yes No

Type and Frequency

Occupation:

Family History-

Does anyone in your family have any of the following? If so, list your relation to them:

Breast Cancer

Stroke

Colon Cancer

Epilepsy/Seizures

Ovarian/Uterine Cancer

GallBladder Disease

Melanoma

Bleeding/Clotting History

Prostate Cancer

Diabetes

Lung Cancer

Heart Disease

Pancreatic Cancer

Lung Disease

Lymphoma/Leukemia

High Blood Pressure

Thyroid Cancer

High Lipids/Cholesterol

Skin Cancer

Hemorrhoids

Other Cancer (Type and Family Member)

Other

Will you absolutely refuse blood transfusions, if necessary? Yes No

X-RAYS/LABWORK DONE: Never

Yes

Type and location

Are you currently being treated by a physician for any of the following? If yes, please check boxes for all that apply.

Please explain any “Yes” answers at the bottom of this page

General:

Weight Loss Weight Gain Fever/Chills

Gastrointestinal:

Last Colonoscopy (year):

Last Flex. Sig. (year):

Last Stool Occult Blood Test:

Diarrhea Blood in stool Abdominal pain Heartburn Constipation

Neurologic:

Headache Weakness Dizzyness Numbness / tingling

Eyes:

Glaucoma Cataracts Recent vision changes

Cardiovascular:

Chest pain Irregular Heartbeat Shortness of breath Feet / leg swelling Varicose veins

Urinary:

Painful urination Slow/frequent urination Infections Blood in urine Kidney stones

Psychiatric:

Depression Trouble sleeping Schizophrenia Alcohol dependency Drug dependency

Respiratory:

Cough Trouble breathing Wheezing Pneumonia

Women Only:

Last Pap Smear(Year):

Number of pregnancies

Number of Deliveries

Venereal disease Menstrual irregularities Vaginal discharge

Breast:

Last Mammogram (Year):
Monthly self exams Lumps Nipple discharge Pains

EAR/NOSE/MOUTH/THROAT:

Hearing loss Nose bleeds Gum problems Sore throat Hoarseness Trouble swallowing

Hematologic/Lymphatic:

Easy bleeding or bruising Anemia

Blood transfusion:

Immunologic:

HIV / AIDS Hepatitis (A, B, or C?)

SKIN:

Rashes / dermatitis Changes in moles

Musculoskeletal:

Fractures/dislocations Muscle pain/cramps

MEN ONLY:

Last Prostate Exam (Year):

Last PSA Test (Year):

Prostate disease Testicular lumps, pain Venereal disease

Please explain any “Yes” answers below:

Credit Card on file Policy

Please complete this form in its entirety. This form serves as confirmation that you are aware that Northstar Surgery Specialists P.A. has a policy that requires each patient to follow a payment plan with a credit card on file.

-hereby consent to follow the payment agreement given below with strict abidance. Should I have any difficulty, I fully accept it as my responsibility to report this matter to Northstar Surgery Specialists before my next payment, so as to allow for alternate arrangements to be made. This policy is in effect due to the raise in patient deductibles and patient responsibility due to the change in health insurance policies and guidelines. If you have any questions about your coverage, please contact your insurance company on the number listed on the back of your insurance card.

If surgery is required, a cost estimation will be provided to you prior to surgery upon request. The benefit of this form is that no cost will be collected up front prior to surgery. By signing below, this allows us to set you up on a payment plan of $100/month for any and all charges incurred from office visits and operations. If you decline to put your card on file, you will be responsible for paying your amount due in full PRIOR TO SERVICES, unless alternate payment arrangements have been agreed upon by the billing administrator of NorthStar Surgery Specialists,P.A.

Patient Name: Date of Birth: Email:

YOU WILL RECEIVE A CONFIRMATION EMAIL PRIOR TO ANYTHING BEING CHARGED ON YOUR CREDIT CARD

The below credit card will be used for any charge incurred from office visits/operations. This card will be set up for a payment plan of $100/month after insurance’s final determination unless otherwise specified (defaults to the 1st day of every month unless otherwise specified)

Please enter your credit card number:

Expiration Date:

CVV:

Billing Zip Code:

Day of the month you would like your card to run:

Sign:

Date:

Or

I decline to put my card on file, with the understanding that will be responsible for payment in FULL of any balance prior to any procedure performed/office visit.

Sign:

Date: