Patient Update Form

Name of all associated patients:

Date of Birth:

Address:

Phone:

Email for clinic communication:

Pharmacy:

Emergency Contact:

Name

Phone:

Relationship

For MINORS (under 18 years of age):

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

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Primary Insurance Information

Company

ID #

Grp #

Guarantor

Secondary Insurance Information

Company

ID #

Grp #

Guarantor

Insurance and Payment Policy:

It is your responsibility to bring your insurance card and ID 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 as well as any past balance. All payments are due at the time of service and if a minor, whoever is accompanying the child for the visit is responsible for payment. Please contact your insurance company regarding any questions you have regarding your coverage. By initialing below, I have read and understood the payment policy.

Physicals and Wellness Exams:

Physicals and wellness exams are preventative care and if any other symptoms are present at the time of visit rescheduling may be necessary. Charges will apply if preventative and diagnostic visit occur. By initialing below, I have read and understood the physical and wellness exam policy.

No show or Tardiness and dismissal from the practice

We strive to offer excellent service to our patients in a timely manner. Please arrive 15 minutes before your scheduled appointment time. We request 24-hour notice for cancellations. We reserve the right to charge a $25 fee for cancellations and no shows. Multiple missed appointments may lead to discharge from the practice. By initialing below, I have read and understood the no show or tardiness and dismissal from the practice policy.

Advanced Practice Nurse Consent for Treatment

The facility has an on staff advanced practice nurse to assist in the delivery of medical care. An advanced practice nurse is not a doctor. As advanced practice, a 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. 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. By initialing below, I have read and understood the advanced practice nurse consent for treatment policy.

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 initialing below, I have read and understood the provider-patient relationship 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

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