Patient Update Form

Name of all associated patients:

Name of all associated patients

Date of Birth:

Address:

Phone:

Email for clinic communication:

Pharmacy:

Emergency Contact:

Name

Phone:

Relationship

For MINORS (under 18 yrs of age):

List of authorized individuals who have consent to treat a minor:

Add new row

Primary Insurance info:

Company

ID #

Grp #

Guarantor

Secondary Insurance info:

Company

ID #

Grp #

Guarantor

Insurance and Payment Policy:

It is your responsibilty to bring your insurance and ID card to each visit, know the limits and coverage of your health insurance policy, update any changes to your policy, and be prepared to pay any patient portion due at the time of service. Please contact your insurance company regarding any questions regarding your coverage. By signing below, I have read and understood the payment policy.

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

Signature:

Date

No Show and Tardiness

We strive to offer excellent service to our patients in a timely manner. Please arrive 15 mins before your appointment. It is unfair to others if you miss or fail to arrive timely for your appointment. We request a 24 hour notice for appointment cancellations. We reserve the right to charge a $25 fee for late cancellations and no shows. Multiple missed appointments may lead to discharge from the practice. By signing below, I have read and understood the no show and tardiness office policy.

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

Signature:

Date:

Advanced Practice Nurse Consent for Treatment

This facility has on staff an advanced practice nurse to assist in the delivery of medical care. Advanced practice nurse is not a doctor. An advanced practice nurse is a registered nurse who has received advanced education and training in the provision of health care. An advanced practice nurse can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. In addition, the advanced practice nurse may treat minor lacerations and other minor injuries. By signing below, I have read the above and hereby consent to the servers of an advanced practice nurse for my health care needs. I understand that at any time I can refuse to see the advanced practice nurse and request to see a physician if a physician is available.

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

Signature:

Date:

Provider Patient Relationship

We strive to offer evidence-based patient centered medical care for your entire family. We abide by the guidelines and vaccine schedule set forth by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), and the Centers for Disease Control (CDC). Keeping your optimal care as our top priority, we judiciously prescribe antibiotics only when medically necessary, we do not prescribe cough medications, and work hard to provide comprehensive medical care to serve as your medical home . By signing below, I have read and understood the provider patient relationship and find this practice philosophy to be a good match.

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

Patient/Parent/Guardian Name:

DOB

Other patient minors associated with guardian:

DOB

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