New Patient Packet Form

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EMERGENCY CONTACT

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CURRENT INSURANCE INFORMATION

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Welcome to our office. We are committed to providing the best, most comprehensive care possible. We encourage you to ask questions. Please assist us by providing the following information. All information is confidential and is released only with your consent.

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.

NEW PATIENT QUESTIONNAIRE

PLEASE LIST ALL MEDICATIONS THAT YOU ARE TAKING, BOTH REGULAR MEDS AND "AS NEEDED" MEDS. PLEASE INCLUDE INHALERS, CREAMS, DROPS, & SUPPLEMENTS. PLEASE LIST THE NAME, STRENGTH, DOSE, AND FREQUENCY (HOW OFTEN YOU TAKE IT)

See the examples, and list your meds in a similar fashion

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PLEASE LIST ANY SURGERY YOU HA VE HAD IN THE PAST AND THE APPROXIMATE YEAR THAT THE SURGERY WAS DONE - Please list them from most recent to most distant.

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PLEASE LIST ANY ALLERGIES TO MEDICATIONS AND THE SPECIFIC REACTION YOU HAD TO THAT DRUG (Rash, trouble breathing, etc.)

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FAMILY HISTORY

MOTHER

FATHER

BROTHERS & SISTERS: LIVING

IF DECEASED

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How many children do you have?

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SOCIAL HISTORY

ALCOHOL DRUG USE

OCCUPATION

Please list all jobs from most recent to most distant

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REVIEW OF SYSTEMS

Please note any symptoms or conditions you are experiencing

GENERAL

EYES

EARS

Nose/Throat

Cardiovascular

Gastrointestinal

Musculoskeletal

Neurological

Urological

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.

Cancellation Policy/No Show Policy For Doctor Appointments

1. Cancellation/ No Show Policy for Doctor Appointment

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment.

Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly "full" appointment book. If an appointment is not cancelled at least 24 hours in advance you will be charged a fifty dollar ($50) fee; this will not be covered by your insurance company.

2. Scheduled Appointments

We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time we will have to reschedule the appointment.

3. Account balances

We will require that patients with self-pay balances do pay their account balances to zero ($0) prior to receiving further services by our practice. If you have questions about your bills or who would like to discuss a payment plan option may call and ask to speak with our business office representative with whom they can review your account and concerns. Patients with balances over $100 must make payment arrangements prior to future appointments being made.

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.

Authorization for Release of Medical Records

have given authorization for any and all medical records describing my health history, symptoms, examinations, test results, diagnoses, treatments and any plans for future treatment to be released as follows:

To:

Malladi R. Sastry, M.D., P.A.
4100 W. 15th Street Suite 216
Plano, TX 75093
Phone: (972)596-2135
Fax: (972)596-2420

Thank you for your cooperation.

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.

4100 West 15th Street, Suite 216, Plano, TX 75093 Phone (972) 596-2135 Fax (972) 596-2420

PATIENT CONSENT FORM

I, as a patient of Dr. Malladi Sastry, understand that as a part of my health care that the practice originates and maintains health records describing my health history, symptoms, examinations, test results, diagnoses, treatment and any plans for further care or treatment including referrals. I also understand that this information is utilized to plan for my care and treatment, to bill for services provided to me, and to communicate with other health care providers and other health care operations.

The Physicians Notice of Privacy Practices provides specific information and complete description of how my personal health information may be used and disclosed. I have been provided a copy or access to the Notice of Privacy Practices and understand that I have a right to review the notice prior to signing this consent.

I understand that the physician reserves the right to change the Notice of Privacy practices and that I can request any changes be sent to me at the address listed below. I understand that I do have the right to restrict the use and/or disclosure of my personal health information and that the physician is not required to agree to treatment, payment or healthcare operations. I am free to revoke this consent anytime in writing.

I authorize the physician to release medical information that may be necessary to request reimbursement from insurance companies to whom I have submitted a claim. I assign all medical and surgical benefits, to include major medical benefits to which I am entitled, to the physician. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

I understand that any and all records whether written, oral or in electronic format are confidential and cannot be disclosed without my prior written authorization, except as otherwise provide by law.

This document serves as written consent based on the fact that I have been provided and have reviewed the Physician's Notice of Privacy Practices.

I voluntarily consent to the medical treatment and understand that no guarantees are made as to the results. I also give my consent to have my picture taken and placed in my medical record.

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'S FINANCIAL RESPONSIBILITY AGREEMENT

PLEASE CHECK EACH PARAGRAPH AFTER READING AND SIGN THE BOTTOM

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.

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