New Patient Packet

Please complete this form to insure your complete medical history is captured for the staff & providers review. Thank you in advance for your cooperation. 😀

Full Name:

Date:

Birth Date:

Age:

ADVANCE DIRECTIVE/DNR (age 18 or older)

Do you have an advance directive or a DNR (Do not Resuscitate) paperwork in place?

Yes No

If yes, please provide our office a copy at your earliest if not it is a requirement for our office to provide you paperwork in regards to this matter. Thank you in advance for your cooperation.

DRUG ALLERGIES/ADVERSE REACTION

NO DRUG ALLERGIES

Add New Allergy/Adverse Reaction Name:

MEDICATIONS (PLEASE LIST ALL NAMES, DOSAGE AND TIME PER DAY. Ex: Aspirin 81 mg one a day)

No Long Term Medications Taken

Add new medication

SCREENING AND PREVENTION TESTING HISTORY

Please indicate below the information as requested to the best of your recollection. If you have any medical records to support these testing we would appreciate a copy otherwise, we can do our best to obtain the information. Enter information only applicable to you based on age, sex etc…

Colonoscopy Date:

Location:

Abnormal Result:

Y N

Mammogram Date:

Location:

Abnormal Result:

Y N

Pap Smear Date:

Location:

Abnormal Result:

Y N

Bone Density:

Location:

Abnormal Result:

Y N

VACCINATION HISTORY

Please indicate below to the best of your recollection the last immunization record for the below vaccinations. Please bring proof of immunization record if you have it.

Patient refuses ALL vaccinations/immunizations

Tetanus Booster (TD) or Tdap Date:

Prevnar (PCV 13) Date:

Influenza (Flu vaccine) Date:

Pneumovax (PPV23) Date:

Zostavax (old shingles) Date:

HPV ( Gardasil 9 date of all 3)

Shingrix (new shingles) Date:

MMR ( measles, mumps, rubella)

Add another vaccine

PERSONAL MEDICAL HISTORY

Please select all that apply below:

Alcoholism/Drug Abuse:

CURRENT PAST

COMMENTS:

Asthma:

CURRENT PAST

COMMENTS:

Cancer

CURRENT PAST

What type of cancer?

COMMENTS:

Depression/Anxiety:

CURRENT PAST

COMMENTS:

Type 1 Diabetes:

CURRENT PAST

COMMENTS:

Type 2 Diabetes:

CURRENT PAST

COMMENTS:

Emphysema (COPD)

CURRENT PAST

COMMENTS:

Heart Disease

CURRENT PAST

COMMENTS:

High Blood Pressure

CURRENT PAST

COMMENTS:

High Cholesterol

CURRENT PAST

COMMENTS:

Hypothyroidism/Thyroid disease

CURRENT PAST

COMMENTS:

Migraine Headaches:

CURRENT PAST

COMMENTS:

Renal (kidney) Disease:

CURRENT PAST

COMMENTS:

Acid Reflux (Gastroesophageal Disease)

CURRENT PAST

COMMENTS:

Stroke:

CURRENT PAST

COMMENTS:

Add another medical history

SURGICAL HISTORY

Please indicate below all significant surgical history that will be pertinent for us to know. Example would be gallbladder removal (cholecystectomy), total abdominal hysterectomy, partial hysterectomy, vasectomy, knee replacement, breast augmentation/implants etc….

Add another surgery

FAMILY MEDICAL HISTORY:

NO SIGNIFICANT FAMILY HISTORY IS KNOWN

UNKNOWN/ADOPTED

Add another family history

PLEASE LIST WHICH FAMILY MEMBER HAD THE CHECKED MEDICAL HISTORY (MOTHER, FATHER, GRANDPARENT, SIBLING OR CHILD)

Important information for us to know would be if any of the above family members are deceased due to any of the above conditions? If yes, please indicate who and the cause of death if known please. We apologize in advance for we acknowledge the sensitivity of this information. Thank you

SOCIAL HISTORY

TOBACCO (CHEW, CIGAR, PIPE, CIGARETTE)

Do you use tobacco products now or in the past?

Yes

Number of years:

Number of packs per day:

Former Smoker

Quit Date:

NICOTINE (VAPE)

Never Current Former

ALCOHOL

Do you drink alcohol?

Non-Drinker

Yes

Daily

how much?

Socially

how often?

Rarely (i.e. special occasions/holidays etc)

Type:

Beer

Wine

Liquor

Former Drinker

Yes

Quit Date:

RECREATIONAL DRUGS:

Never

Current

Social/Occasional

What drug(s)?

Former User

What drug(s)?

Thank you in advance for taking the time to complete our patient history intake form.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Patient Signature:

Date

Date:

Date of Birth:

PLEASE PRINT:

Last Name:

First Name:

Middle Name:

Address Street:

City:

State:

Zip:

Race:

Ethnicity:

Marital Status:

Sex:

Preferred Language:

Preferred Phone Number:

Additional Phone Number:

Home/Cell/Work:

Email Address:

Social Security Number:

Name of Primary Insurance Carrier:

Copay:

Member ID #:

Group ID #:

Subscriber Information for Insurance: (If other than the patient).

Name:

Relation:

Address:

Phone Number:

Date of Birth

PREFERRED PHARMACY: This information is very important.

Pharmacy Name and Location:

Pharmacy Phone Number:

EMERGENCY CONTACT

Name:

Relation:

Address:

Phone Number:

Date of Birth

AUTHORIZATION TO TREAT

I (and/or the undersigned on behalf of the patient) voluntarily consent to allow Burrows Family Practice and staff to provide such evaluation and/or care and treatments as deemed advisable and necessary.

I understand that although care is reviewed and supervised by BFP physicians, actual care may be rendered by physician extenders (i.e. physician assistants or nurse practitioners).

I understand that should I execute a Durable Power of Attorney for Health Care or other Advance Directive, I will provide an executed copy to my physician. I further understand that I will notify my physician of any changes in the Directive.

I understand that I will be informed about the course of my treatment. Also, I am free to terminate my treatment with BFP at any time.

CONSENT FOR TREATMENT:

I, the undersigned, do hereby authorize and consent to medical treatment which is deemed advisable and is to be rendered under the general or special supervision of our medical staff. This consent will remain in effect from the date of initiation through the duration of my treatment.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Print Patient Name:

Date of Birth:

Signature of Patient or Legal Representative:

Date:

FINANCIAL POLICY

INSURANCE:

Our practice participates in a variety of insurance plans. It is your responsibility to:

BRING IN YOUR INSURANCE CARD TO EVERY OFFICE VISIT.
CO-PAYS AND DEDUCTIBLES ARE DUE AT THE TIME OF THE OFFICE VISIT, IF NOT COLLECTED THERE WILL BE A $25.00 BILLING FEE. COINSURANCE IS BILLED AFTER YOUR INSURANCE COMPANY HAS PAID ITS PORTION OF THE CLAIM.
PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE FOR ANY MEDICAL CARE NOT COVERED BY YOUR INSURANCE. IF WE CANNOT VERIFY INFORMATION AT TIME OF SERVICE WE WILL TAKE CASH PAYMENT AND REIMBURSE YOU WHEN INSURANCE IS PAID.

SELF PAY PATIENTS:

Payment for office visit is due at the time of service.

RETURNED CHECK FEE:

You will be charged $25.00 for a returned check from your bank for any reason.

CANCELLED APPOINTMENTS:

This office requires a 24-hour notice if you are unable to keep your scheduled appointment. If we do not receive 24-hour notice, you will be charged a no-show fee of $25.00 for missed medical office visits.

REFERRALS:

Please allow three (3) business days from the date of requested referral.

LAB FEES:

Lab fees for blood work and pathology (including PAP smears) are separate from our office charges and may be billed directly to you by the lab company.

ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION:

I assign directly to Burrows Family Practice all medical benefits for services rendered. I understand that I am responsible for all allowable charges whether or not paid by my medical insurance. I hereby authorize the provider to release all my information if necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions. In addition, I am responsible for any deductible, copay and coinsurance amounts.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Print Patient Name:

Date of Birth

Signature of Patient or Legal Representative:

Date:

Notices of Privacy Practices & Acknowledgement Form

By signing below, I acknowledge that Burrows Family Practice has prepared a Notice of Privacy Practices, which informs me how Burrows Family Practice uses and discloses my protected health information and what my privacy rights are in regards to that information. I may obtain a copy of the full, detailed Privacy Notice by asking a Burrows Family Practice front office employee. By signing below, I acknowledge that I am aware Burrows Family Practice has revised their original Notice of Privacy Practices and that I may request a copy of it.

REQUEST FOR CONFIDENTIAL INFORMATION COMMUNICATION

I authorize BFP to leave messages on my answering machine/voice mail pertaining to appointments or payment issues and to send correspondence to the address provided for the insurance holder unless other arrangements are made in advance. I understand that BFP will utilize text messages to notify patients about future appointments and other important notifications if needed. I understand that BFP Providers may use a HIPAA compliant virtual medical scribing service that will assist in documenting the patient visit through secure recorded encounters. This data is encrypted in compliance with federal and state regulations.

PERMISSION TO DISCUSS PERSONAL HEALTH INFORMATION WITH OTHER INDIVIDUALS

Individuals to whom Burrows Family Practice may disclose my Personal Health Information for coordination of care purposes. I hereby grant BFP permission to discuss my health information with persons listed below as it relates to my care.

Add new row

I understand that if I do not list anyone and am not present or am incapacitated, BFP may share my information with family or friends that BFP has determined it is in my best interest and necessary for coordination of care.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Print Patient Name:

Date of Birth:

Signature of Patient or Legal Representative:

Date:

Nurse Practitioner / Physician Assistant Consent Form:

Burrows Family Practice has on staff a PA/NP to assist in the delivery of medical care. A Physician Assistant (PA) / Nurse Practitioner (NP) is not a doctor. A PA/NP is a graduate of a certified training program and is licensed by the state board. Under the supervision of a Physician, a PA/NP can diagnose, treat and monitor acute and chronic diseases as well as provide health maintenance care. Supervision does not require the constant physical presence of the the physician, rather the overseeing of activities of and accepting responsibility for the medical services provided.

I (print Patient Name) (Date of Birth) have read the above information, and consent to the services of a PA/NP for my health care needs. I understand I can refuse the service of a PA/NP at anytime and request the service of the Physician.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Print Patient Name:

Date of Birth:

Signature of Patient or Legal Representative:

Date:

Electronic Communication Consent Form:

Completion of this form allows BFP to communicate with you electronically regarding your protected health information. This portal is not intended for any urgent medical needs or appointment requests. A response will be given within 4 business days.

PATIENT'S ACKNOWLEDGMENT AND AGREEMENT: I have read the above information.

I choose NOT to activate my portal account.

Yes, I would like to activate my portal account. I understand BFP cannot guarantee complete security and confidentiality in communication electronically, and will not be liable for inadvertent disclosures of confidential information that occurs outside the scope of our security measures.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Patient Email Address:

Patient Signature:

Date:

Telehealth Consent Form

1. My health care provider wishes me to engage in a telehealth consultation and has explained to me how the video conferencing technology will be used to affect such a consultation and that it will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

2. I have met the following criteria for a telehealth consultation:

I have an Apple device with Facetime for the consultation
I have an Android device with WhatsApp Messenger installed on my smart phone for the consultation

3. I understand there are potential risk to this technology, including interruptions, unauthorized access and technical difficulties. I further understand that my healthcare information may be shared with other individuals for scheduling, billing purposes and video operation, and that I will be informed of their presence. I have the right to request the following: 1) omit specific details of my medical history/physical examination 2) ask non-medical personnel to leave the telehealth exam room and or 3) terminate the consultation at any time.

4. I understand that billing will occur from my practitioner for this telehealth visit. Co-payments will be due and payable before the telehealth consultation. Payments may be made on the www.BurrowsFamilyPractice.org website.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient First Name:

Last Name:

Date of Birth:

Patient's Signature:

Date:

Your information will be encrypted.

New Patient Packet

ADVANCE DIRECTIVE/DNR (age 18 or older)

DRUG ALLERGIES/ADVERSE REACTION

MEDICATIONS (PLEASE LIST ALL NAMES, DOSAGE AND TIME PER DAY. Ex: Aspirin 81 mg one a day)

SCREENING AND PREVENTION TESTING HISTORY

VACCINATION HISTORY

PERSONAL MEDICAL HISTORY

SURGICAL HISTORY

FAMILY MEDICAL HISTORY:

SOCIAL HISTORY

AUTHORIZATION TO TREAT

CONSENT FOR TREATMENT:

FINANCIAL POLICY

INSURANCE:

SELF PAY PATIENTS:

RETURNED CHECK FEE:

CANCELLED APPOINTMENTS:

REFERRALS:

LAB FEES:

ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION:

Notices of Privacy Practices & Acknowledgement Form

REQUEST FOR CONFIDENTIAL INFORMATION COMMUNICATION

PERMISSION TO DISCUSS PERSONAL HEALTH INFORMATION WITH OTHER INDIVIDUALS

Nurse Practitioner / Physician Assistant Consent Form:

Electronic Communication Consent Form:

Telehealth Consent Form

Burrows Family Practice, Inc.