Omega Family Medicine REGISTRATION PATIENT INFORMATION Name _____________________________________________________________________ (Last) (First) (Middle Initial) Social Security # _____/____/______ Address ________________________________________________City _________________________State _____ Zip__________ Date of Birth _____/_____/______ Home Phone ( ) _____ - _______ Cell Phone ( ) _____ - _______ E-mail _________________________________________________ Occupation ____________________________________ Sex M F Age __________ Race ________________________ Married Partnered for _____ years Pharmacy _____________________________________________ Separated Minor Employer/School Address ________________________________ Widowed Single Employer/School Phone ( ) _____-_______ Divorced * In case of emergency, who should be notified? ___________________________________ Phone ( ) _____ - _______ Relationship to Patient _____________________________________ ** Whom may we thank for referring you? _______________________________________ CANCELLATION POLICY We kindly request that patients give 24 hours’ notice if unable to keep a scheduled appointment. With proper notice given we will gladly reschedule the patient to another day and time at no charge. If less than 24 hours’ notice is given the patient will be charged $10. Patients who are not present for a scheduled appointment and fail to give notice will be billed $25.00. Patient Signature ____________________________________________________________ ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage and assign directly to OMEGA FAMILY MEDICINE all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid by insurance or not. I authorize the use of my signature on all insurance submissions. OMEGA FAMILY MEDICINE may use my health care information to my designated insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. X_____________________________________________________________________________ Date _____/_____/______ (Signature of Patient, Parent/Guardian, or Personal Representative ___________________________________________________________________ _______________________________ (Please PRINT name of Patient, Parent/Guardian, or Personal Representative) Relationship to patient Omega Family Medicine HEALTH HISTORY Patient Name: ______________________________________________ Date of Birth: ____/_____/_______ Allergies: _________________________________________________________________________ Medications: (please list) NAME: STRENGTH: DOSE: Vaccination Status: (please list date if possible; or year) Hepatitis #1, #2, #3: ________________________ Influenza: ________________________ Pneumococcal: ________________________ Tetanus: ________________________ Health Maintenance: (please list date if possible; or year) Bone Density Scan: ________________________ Carotid Ultrasound: ________________________ Colonscopy: ________________________ EKG: ________________________ Echocardiogram: ________________________ Mammogram: ________________________ Pap Smear/Pelvic Exam: ________________________ Pulmonary Function/Spirometry: ____________________ Stress Test: ________________________ Childhood Illness: (please indicate yes or no) Measles: ___________________ Mumps: ___________________ Chicken Pox: ___________________ Other Major Medical Problems/Conditions: _________________________________________________________ ADULT MEDICAL HISTORY: Surgeries/Hospitalizations: Surgeries/Hospitalizations Date Surgeon Hospital Family History: (please list all known diseases or conditions) Father Medical History: ________________________________________________________________________ Mother Medical History: _______________________________________________________________________ # of Children: _________________ Children Medical History: _______________________________________________________________________ # of Siblings : _________________ Siblings Medical History: ________________________________________________________________________ Paternal Grandmother Medical History: ____________________________________________________________ Paternal Grandfather Medical History: _____________________________________________________________ Maternal Grandmother Medical History: ___________________________________________________________ Maternal Grandfather Medical History: ____________________________________________________________ Social History: Marital Status: __ Married __ Single __ Partnered for ___ years __ Separated __ Minor __ Widowed __ Divorced Who do you live with? __________________________________________________________________________ In your home, are there? (please check all that apply) __ Pets __ Smoke Alarm __ Smoke Free Work __ Carbon Monoxide Detector __ Smoke Free Home __ Guns in the Home? Please indicate your: Highest education level: ___________________________ Occupation: ___________________________ Diet: ___________________________ Sleep Habits: ___________________________ Tobacco Use Frequency: __________ times per ________ Type of tobacco: ________________________ Alcohol Use Frequency: __ Daily __ Weekly __ Monthly Amount:__________ drinks per ___________ Drug Use: _______________________________________ Caffeine Use: ___________________________ Exercise: ________________________________________ Tattoos/Piercings: _______________________ Sexually Active: __ Yes __ No Contraceptive Use: __ Yes __ No Karisa Young, N.P. – Michael Wilt – P.A. William F. Mills, MD – Supervising/Collaborating physician HIPAA Compliant Authorization Form Patient Name: _______________________________________ Date of Birth: _____/_____/_____ Social Security #: _____/_____/_____ I hereby authorize _______________________________________________________ (Name and address of person required to make disclosure-Previous Health Care Provider) release to: Omega Family Medicine 401 North Eighth Street Olean, NY 14760 PHONE (716)379-8113 FAX (716)379-8115 All medical records that are in your possession for the last three (3) years, or records that are specified below: **LAST 2 YEARS OF MEDICAL DOCS, MEDICATION LIST, and IMMUNIZATION RECORDS.** ADDITIONAL: ____________________________________________________ Purpose of this disclosure is being made at the request of the individual for the following: _____ Change of primary care physician _____ Coordination of care _____ Other (please specify) ________________________________________ THIS AUTHORIZATION EXPIRES ONE YEAR FROM THE DATE BELOW. _________________________________ (Signature of patient) _________________________________ (Signature of witness) _____/_____/_____ (date) _____/_____/_____ (date) !" # #!$ %&#! 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