Christina M. Mcalpin, M.D.

Registration Form

Today's Date

Primary Care Physician

Patient's Last Name

First

Middle

Title

Mr. Miss Mrs. Ms.

Martial Status

Single Married Divorced Separated Widow

Is this your legal name?

Yes No

If not, what is your legal name?

Social Security Number

Birth Date

Age

Sex

Male Female

Street Address

City

State

Zip

Home Phone

Mobile Phone

Email Address

Occupation

Employer

Employer Phone Number

I was referred to this clinic by

Dr. Insurance Plan Hospital Family Friend Close to home/work Yellow Pages Other

Other family members seen here:

In Case of Emergency

Name of local friend or relative

Relationship to Patient

Home Phone Number

Cell Phone Number

The above information is true to the best of my knowledge. I authorize my insurance benefits to paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Christina M. Mcalpin, M.D. or insurance company to release any information required to process claims.

Patient/Guardian Signature

Disclaimer: 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.

Date

Patient Financial Agreement Form

Date

Patient Name

Date of Birth

Dr. Mcalpin requires this form to be signed by her patients. We appreciate your cooperation. If you have any questions, please speak with Billing Department. We are pleased to assist you with your insurance.

Financial Responsibility: I understand that with the exceptions explained below, I am personally responsible for any medical fees I will incure with Dr. Christina M. Mcalpin.

I also understand that I will be responsible for any charges incurred by not providing the most current and correct insurance information to Dr. Christina M. Mcalpin. Exception to this policy is: those patients with current authorization with HMO, state or federally funded programs or PPO in which Dr. Christina M. Mcalpin is currently contracted with.

Patient or Legal Guardian Signature:

Disclaimer: 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.

Date

Authorization to Pay Benefits to Physician: I hereby authorize payment for medical services provided directly to Dr. Christina M. Mcalpin.

Patient or Legal Guardian Signature:

Disclaimer: 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.

Date

Dr. Christina M. Mcalpin will be responsible for billing and collection on professional charts. Dr. Mcalpin is not responsible for any bills you may receive from the Hospital including Anesthesia, Pathology or Laboratory services when surgery is performed. Please be aware that most surgery cases performed may require and assistant to be present, not all assistance may be contracted with your insurance policy. We will do our best to acquire a contacted assistant but this is solely based on availability of the assistant. I understand and agree with the terms and conditions listed above.

Patient or Legal Guardian Signature:

Disclaimer: 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.

Date

Pharmacy Location

Patient Name

Date of Birth

Pharmacy Name

Rite Aid Walgreens Costco Target CVS Other Pharmacy

Pharmacy Address

Pharmacy Number

Patient History Form

Patient Name

Date

What brings you here today?

Have you had any type of surgery?

Yes No

Which one?

Do you take medication?

Yes No

Which ones?

Have you ever been admitted to the hospital?

Yes No

When & why?

Are you allergic to any medication?

Yes No

Which ones?

Family History: What is the health status of your family?

Father

Medical Problem

If deceased, cause of death

Mother

Medical Problem

If deceased, cause of death

Brother

Medical Problem

If deceased, cause of death

Sister

Medical Problem

If deceased, cause of death

Other

Medical Problem

If deceased, cause of death

Social History

How much alcohol do you drink daily?

Monthly?

What kind of alcohol do you drink?

How many packs of cigarettes do you smoke a day?

For how many years?

Do you use any illegal drug?

Yes No

Which one?

Your information will be encrypted.

Christina M. Mcalpin, M.D. - Patient Forms

Registration Form

In Case of Emergency

Patient Financial Agreement Form

Pharmacy Location

Patient History Form

Family History: What is the health status of your family?

Father

Mother

Brother

Sister

Other

Social History