Regional Physicians PRIMARY CARE
tm High Point Regional Health System
Adams Farm Shopping Center 5710-1 High Point Road Greensboro, NC 27407 Phone: (336) 299-7000 Fax: (336) 299-7003
Welcome to Regional Physicians Primary Care. We are pleased that you have chosen us to be your primary care provider. Enclosed you will find our New Patient Packet. In order for us to schedule your appointment we need you to thoroughly complete the enclosed packet and return to us via mail, fax or you may drop it off at our office. We are open M-F from 8-5 and are closed between 12-1pm for lunch. It is VERY IMPORTANT that the last two pages of the packet be completed in full. In the event that these two fonns are not completed in full, we will return them to you for proper completion prior to scheduling your appointment. If you are transferring your healthcare from another provider or facility to our office, you may contact that physician or facility to have them transfer your records to us. However, for your convenience there is a "release of medical records" enclosed. If you would like for us to request your records, please complete this fonn in its entirety. *Please note: Children ages 18 & under- we MUST have their immunization record(s) prior to their scheduled appointment. As a new patient, please arrive 30 minutes prior to your scheduled appointment. Bring your insurance card, photo ill, any necessary eyeglasses and ALL medications in their original containers. Copays and deductibles are due at the time of service. If you do not have insurance you will be responsible for payment in full at the time of your visit. Thank you again for choosing Regional Physicians Primary Care. We look forward to serving your healthcare needs.
REGIONAL PHYSICIANS PRIMARY CARE Adams Farm Shopping Center 5710-1 High Point Road Greensboro, NC 27407 Phone: (336) 299-7000 Fax: (336) 299-7003
PATIENT INFORMATION Social Security No.:
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Patient's Full Legal Name:
_ ( First
Sex: _F _M
Birth Date __' __'
Race:
Middle
I.:ISI)
Spoken Language:
_
Marital Status: Single_ Married_ Widowed_ Divorced_ Separated_ Address: Street
City Address:
Employer:
Home Phone: (
_ Zip Code
)
Work Phone: (
Email:
_
)
Cell Phone:(
)
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Referring Provider Name:
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How did you hear about us? (circle all that apply) Family / Friend / Insurance / Employer/ Internet / WebsiteIBlllboardl Newspaper !Mailer !Radio /Seminar/ Sports Team Support' TVI Yellow Pages Primary Insurance:.
Subscriber ID:
Subscriber Name:
Group #:
Subscriber's Soc. Sec. 1#:
Subscriber's Date of Birth:
Secondary Insurance:
_ _ _
Subscriber ID:
_
Subscriber Name:
Group #:
Subscriber's Soc. Sec. 1#:
Subscriber's Date of Birth:
_ _
"*Please have your insurance card(s) and photo ID ready to be copied.*.. Spouse's Name:
Work Phone: (
Emergency Contact: Home Phone: (
_ Cell Phone (
),
)
_ _
~Relationship:
)
Work: (
)
Cell: (
)
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IF PATIENT IS UNDER 18 YEARS OLD, PLEASE COMPLETE PARENT/GUARDIAN SECTION BELOW. Parent/Guardian Name:
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Address:
_
(If different from above)
Home Phone: ( Social Security #:
)
Street
City
Work: (
)
State
Up Code
Cell: ( Date of Blrth:
) Sex:
Marital Status: Single _ _ Married _ _ Widowed _ _ Divorced _ _ Separated_ _
_ .F _ _~M
The undersigned makes the following acknowledgments and agreements regarding treatment to be provided to the patient whose name appears above: I - Consent to treatment: I consent to any medical or surgical treatment rendered to the patient under general or special instructions of the physician. I certify that no guarantee of assurance has been made to me as to the results which may be obtained. 2 - Release of medical information: I authorize the release of any medical or other infonnation from this provider and other providers necessary to process a health insurance claim or to provide treatment. 3 - Assignment of benefits: I authorize payment of medical benefits to MedVentures, LLC DBA Regional Physicians. I certify that the information given at the time of registration is correct. I understand that I will be financially responsible for all charges in full at the time I am given treatment unless otherwise discussed before I am seen. I understand I am financially responsible to Regional Physicians for charges not covered by insurance.
Signature of Patient or Legal Representative
Date masOS0610
Regional Physicians Primary Care Adams Farm Shopping Center 5710-1 High Point Road, Greensboro, NC 27407 (336) 299-7000 Fax: (336) 299-7003
Notice of Privacy Practices Receipt Acknowledgement I have been presented with a copy of Regional Physician's Notice of Privacy Practices, detailing how my health information may be used and disclosed as permitted under federal and state law. I understand the contents of the notice. Date of Birth
Patient Name (Printed)
Signature of Patient or Guardian (If minor)
Date
1. Please list the family members and/or other persons, if any, whom we my inform about your general medical condition and your diagnosis (including treatment, payment and health care operations): Name:
Phone #:
_
Name:
Phone #:
_
Name:
Phone #:
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2. Please list the family members and/or other persons, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY: Name:
Phone #:
_
Name:
Phone #:
_
Name:
Phone #:
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3. Please list the telephone number(s) where you want to receive calls about your appointments, lab and x-ray results, or other health information:
4. Can confidential messages (i.e. appointment information) be left on your answering machine? _ _ _ _ _ _ _ Yes
_ _ _ _ _ _ _ No
It is your responsibility to update this information as needed• ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• Intemal Use Only If patient or patient's representative refuses to sign acknowledgement of receipt of Notice, please document the date and time the Notice was presented to patient and sign below:
Presented on (date):
Namerritle:
_
REGIONAL PHYSICIANS PRIMARY CARE Adams Fann Shopping Center 5710-1 High Point Road Greensboro, NC 27407 Phone: (336) 299-7000 Fax: (336) 299-7003
CONSENT FOR RELEASE OF MEDICAL RECORDS
From:
Patient's Name Patient's Address Patient's Birth Date Patient's Social Security Number (last" digits only) XXX - XX -
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Records Requested From: PracticelPhysician Name Address Phone I do hereby consent and authorize you to release copies of my medical records. PLEASE NOTE: This authorization includes consent for the release of alcohol, drug, psychiatric infonnation, and any infonnation relating to HIV testing, AIDS, and AIDS-Related Syndrome, which may be included in my records. It also may include infonnation concerning cancer, cancer testing, and cancer results. I agree that a copy of this release or a fax of this release shall be as valid as the original. Please send copies of all requested infonnation as soon as possible to the address listed below. Send all my records Sensitive infonnation has been deleted at the patient's request Send records from (date)
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SEND RECORDS TO:
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PurposelUse oftbe Requested Information nd
_ 2 Opinion _Sharing with other Health Care Provider _Transfer of Care (Patient Sign Discharge Letter to Terminate Care) Patient's Signature
_
Date
Witness Physician Signature revjcJ2J809
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trn Regional Physicians
For office use only: Appointment Dale: Appointment Time: Provider:
HIGH POINT REGIONAL HEALTH SYSTEM
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Scheduler'~s"""in""'it"""ial:-s:-----
Medical History Form
Please complete ยง1!. Information on this form to the best of your knowledge. If none In a particular section, write nla or none.
Patient Name:
Date of Birth:
Name of person completing form:
_ Date:
_
Past Medical History: (Please check all Items that you have had In the past) a Alcohol abuse a Anemia a Arthritis a Asthma a Cancer: o COPD
a Depression a Hypertension a Diabetes 0 Mononucleosis 0 Seizure Disorder a Heartburn a Heart Disease a Stroke 0 Hernia a Tuberculosis 0 High Cholesterol 0 Urinary tract infection
Kidney disease 0 Thyroid disease Liver disease a Migraine headaches Multiple Sclerosis 0 STD: _ 0 Parkinson's disease a 0 Alzheimer's disease 0 - - - - - - a Chronic pain a _ 0
0 0
Allergies: (List allergen name and the type of reaction, write n/a If none) Medication (s): Reaction:
_
Medication (s):
Reaction:
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Food/Insects/Other:
Reaction:
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Immunizations: (List month/year of last Immunization) Tetanus: Gardasil: Hepatitis A:
Hepatitis B: Meningitis: Shingles:
Other: Other: Other:
Family History: (List any major medical conditions that your Mother, Father, Brothers, Sisters, Maternal Grandparents, Paternal Grandparents, Aunts, and Uncles may have. Example Mother/Diabetes)
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I I 1
Social History: Habits: Do you drink alcohol? Cigarette smoking? Past smoking? Chewing tobacco? Any drug use?
Yes Yes Yes Yes Yes
No No No No No
Marital Status: Occupation: Exercise?
How many alcoholic drinks per week? _-::-_ _ Packs Per day: How long? What year did you quit? .,.....-_ _..,...,..._ _ Passive smoker? Yes No Caffeine Use? Yes No How much?
_ _ Yes
No
If yes:
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Education: xlweek
Type:
Present Medications: (List the name and dose of each medication you are currently taking.)
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Surgeries: (Check all surgeries that you have had.) a Appendectomy (appendix) a Inguinal hernia repair a Breast Mass a Laminectomy o Cataract a Lumpectomy Mastectomy o Cholecystectomy (Gall bladder) o Coronary Artery Bypass Prostatectomy (prostate) Thyroidectomy (thyroid) o Hysterectomy
째 째 째
o Tonsillectomy (tonsils) o Umbilical hernia repair o Vasectomy
0
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0
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0
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0
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0
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0
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0
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0 0
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Health Maintenance: (List month/year of last screening/evaluation) Colonoscopy: Flu Vaccine: Mammogram:
Last Pap: Pneumonia Vaccine: PSA:
Bone Density: Cholesterol: Other:
Symptoms: (Check all symptoms that you currently have) General: Chills Fair Health _ Fatigue Fever Good Health _ Night sweats Poor Health _ Sleep difficulties _ Weight Gain _Weight Loss
Neck: Neck Mass Neck Pain Swollen Glands Respiratory: _Cough _ Coughing up blood Shortness of breath _ Sputum production _ Wheezing
Skin: _Bruising _ Changes in Moles _Dryness Hair Loss _Itching/Rash New lesions _ Scalp problems _ Yellowing of skin
Breast: _ Breast pain _ Breast lump _ Nipple discharge
Eye/Ear/NoselThroat: Earache _ Gums bleeding _ Hearing decreased Nose bleeds _ Ringing in ears _Runny Nose Sinus Pain Sore Throat Throat hoarseness Visual disturbances
Gastrointestinal: _ Abdominal pain _ Black, tarry stool _ Constipation Diarrhea _ Difficulty swallowing Nausea _ Rectal bleeding _ Vomiting _ Vomiting blood
Cardiovascular: _Chest pain _ Chest pressure _ Palpitations
Female Genitourinary: _ Pelvic pain _ Urinary Complaints _ Vaginal bleeding problem _ Vaginal discharge Male Genitourinary: Blood in urine _Impotence _ Penile discharge _ Urination difficulty
Endocrine: _ Appetite changes Excessive thirst Hot flashes Hematology: Anemia _ Blood clots in legs
Musculoskeletal: _Joint pain _ Muscle pain Muscle weakness _ Swelling of area: _ _ Neurological: Dizziness _ Fainting spells Headaches _ Memory problems Numbness Seizures Tremors Weakness Psychiatric: _Anxiety _ Depression _ Mood swings
Do you have any specific questions that you want your doctor to address?
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Preferred Pharmacy:
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Address: