Patient Registration Form

Last Name

Apellido

First Name

Nombre

Sex

Male

Hombre

Female

Mujer

Date of Birth

Cumpleaños

SSN

Marital Status Estado civil

Single

Soltero/a

Married

Casada

Divorced

Divorciado/a

Widowed

Viudo/a

Separated

Separados/as

Address

Dirección

City

Cuidad

State

Estado

Zip Code

Código postal

Home Phone #

Numero de teléfono

Cell Phone #

Work Phone #

Email address

Correo electrónico

Referred By

Language

Idioma

Race

Ethnicity

Etnia

Spouse's Name

Nombre de la esposa/o

Spouse's Contact Number

Numero de teléfono

Emergency Contact

Contacto de emergencia

Phone Number

Numero de teléfono

Please upload an image of your Driver's License or ID

Add file

Please upload a file

Employer Information

Employer Name

Empleador

Phone Number

Employer Address

Dirección de empleador

City

State

Zip Code

Patient's Occupation

Insurance Information

Primary Insurance Company

Phone Number

Policy #

Group #

Secondary Insurance Company

Phone Number

Policy #

Group #

Please upload an image of your insurance card

Add file

Please upload a file

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 Signature

Today's Date

Please respond to the following questions by placing a check mark or write the correct answer.

Patient Social History

Tobacco Smoking Status:

Never

Former

Every Day

Someday

Smoking - How Much:

Per Day

Per Week

Tobacco - Years of Use:

Smokeless Tobacco Status:

Never

Former

Every Day

Someday

Chewing Tobacco:

Never

Former

Every Day

Someday

E-Cigarette/ Vape Status:

Never

Former

Every Day

Someday

Has Smoked Since Age:

Alcohol Intake:

None

Occassional

Moderate

Heavy

Alcohol - Years of Intake:

Illicit Drugs:

None

Occassional

Moderate

Heavy

Caffeine Intake:

None

Occassional

Moderate

Heavy

Live Alone or With Other:

Alone

With Other

Number of Children:

General Stress Level:

Low

Medium

High

Diet:

Regular

Vegetarian

Vegan

Gluten Free

Cardiac

Carbohydrate

Low Sodium

Exercise Level:

None

Occassional

Moderate

Heavy

Family History

Is your father

Alive

Deceased

Unknown

Age

Health Problem if any?

Unknown

Is your mother

Alive

Deceased

Unknown

Age

Health Problem if any?

Unknown

Patient Name

Date

Signature

Have you ever had any of the following?

1. Abnormal Chest X-Ray

Yes No

2. Abnormal EKG

Yes No

3. Anxiety, Depression, or Mental Illness

Yes No

4. Blood Problems (Abnormal Bleeding, Anemia, High or Low White Count)

Yes No

5. Diabetes

Yes No

6. Heart Valves or Abnormal Heart Rhythm

Yes No

7. High Blood Pressure

Yes No

8. High Cholesterol or Triglycerides

Yes No

9. Sexually Transmitted Disease

Yes No

10. Stroke or TIA

Yes No

11. Treatment for Alcohol and/or Drug Abuse

Yes No

12. Tuberculosis or Positive Tuberculin Skin Test

Yes No

13. Thyroid or Parathyroid Glands

Yes No

14. Coronary (Heart) Arteries (Angina)

Yes No

15. Arteries Surgery (Aorta, Arteries to Head, Arms, Legs)

Yes No

16. Veins or Blood Clot in the Veins

Yes No

17. Palpitations

Yes No

18. Syncope ('Blackouts', 'Faints', 'Collapse') or Dizziness

Yes No

19. Angioplasty and Atherectomy or PCI (Percutaneous Coronary Intervention)

Yes No

20. Stent Procedure

Yes No

21. A Coronary Artery Bypass Graft (CABG)

Yes No

22. Heart Valve Replacement Surgery

Yes No

23. Cardiomyopathy

Yes No

24. Pacemaker

Yes No

25. Warfarin or Coumadin Management

Yes No

26. Snoring

Yes No

27. Numbness

Yes No

Patient Name

Date

Signature

Surgical History

Knee Surgery

Yes No

When?

Cholecystectomy

Yes No

When?

Colonoscopy

Yes No

When?

Eye Surgery

Yes No

When?

Gastrointestinal Surgery

Yes No

When?

Hernia Repair

Yes No

When?

Hysterectomy

Yes No

When?

Orthopedic Surgery

Yes No

When?

Prostate Surgery

Yes No

When?

Thyroid Surgery

Yes No

When?

Tonsillectomy/Adenoidectomy

Yes No

When?

Vascular Surgery

Yes No

When?

Abdominal Surgery

Yes No

When?

Appendectomy

Yes No

When?

Back Surgery

Yes No

When?

Breast Surgery

Yes No

When?

Cesarean Section

Yes No

When?

Cardiac Catheterization

Yes No

When?

Other

Yes No

When?

If Other, please specify

Patient Name

Date

Signature

Information and Assignment of Benefits

I, authorize the release of any medical information to process this claim. I permit a copy of the authorization to be used in place of the original.

Signature

Date

I hereby authorize Dr. Naim Al-Adli to apply for benefits on my behalf for covered services rendered by him, or by his order. I request that payment from my insurance company be made directly to Dr. Naim Al-Adli (or to the party who accepts assignment).

I certify that the information I have reported regarding my insurance coverage is correct.

I permit a copy of this authorization to be used in place of the original. Either my insurance company or I may revoke this authorization at any time in writing.

Signature

Date

Release of Information

I hereby authorize

to furnish medical records of

covering the periods from

These records are to be released to Fort Bend Heart Center.

I hereby release you, your physician and employees from liability for following this authorization and request.

Patient Signature

Date

Witness

Date

Vein Screening Questionnaire

Patient Name

Date

Do you have or have you ever been diagnosed with:

Varicose vein problems

Yes No

Leg:

Leg or Ankle Ulcers

Yes No

Leg:

Spider Veins

Yes No

Leg:

Do you experience any of the following in your leg(s):

Aching/pain

Yes No

Leg:

Heaviness

Yes No

Leg:

Tiredness/fatigue

Yes No

Leg:

Itching/burning

Yes No

Leg:

Swelling

Yes No

Leg:

Cramps

Yes No

Leg:

Restless legs

Yes No

Leg:

Throbbing

Yes No

Leg:

Skin or ulcer problems

Yes No

Leg:

Do you do any of the following to improve the discomfort to your leg(s)?

Take medication for pain

Yes No

What?

Elevate your legs

Yes No

What?

Wear support hose

Yes No

What?

Personal and Family History

Does anyone in your family have Varicose Veins?

Yes No

If so, who?

Have you ever been pregnant?

Yes No

If so, how many times?

Do you sit or stand for long period of time?

Yes No

For how long?

Do you exercise regularly?

Yes No

How often?

Cancellation/No Show Policy

For Naim Al-Adli M.D. Appointments & Procedure

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; your insurance company will not cover this.

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. Cancellation/No Show Policy for Procedure

Due to the large block of time needed for procedure, last minute cancellation can cause problems and added expense for the office.

If a procedure is not cancelled at least 24 hours in advance you will be charged a seventy-five dollar ($75) fee; your insurance company will not cover this.

Patient Name

Patient Signature

Date

Privacy Practices Acknowledgement

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Name

Date of Birth

Signature

Today's Date

Patient Responsibility

I understand and agree that I am financially responsible for all charges for any and all services rendered. This includes any medical service or visit, routine, examination, refraction, testing, Holter Monitors, and any other screening ordered by the doctor or staff.

I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.

I understand and agree that it is my responsibility to know if my insurance has any deductible, co-payment, co-insurance, out-of-the-network, usual and customary limit, prior authorization requirement or any other type of benefit limitation for the services I receive and I agree to make payment in full.

I understand and agree that it is my responsibility to know if my insurance requires a referral from my primary care physician and that it is up to me to obtain the referral. I understand that without this referral, my insurance will not pay for any services and that I will be financially responsible for all services rendered.

I agree to inform the office of any changes in my insurance coverage. If my insurance has changed or is terminated at the time of service, I agree that I am financially responsible for the balance in full.

If I am a Medicare patient, I understand that I need to provide the office, both my Medicare ID card and my Secondary ID card. If the office does not have the proper information for a secondary insurance, the secondary will not be billed. It will be my responsibility to pay the balance and then file a claim with the secondary for reimbursement.

By signing this form, I consent to the use and disclosure of protected health information about me for treatment, payment and health care operations, and/or as required by law. I have the right to revoke this consent, in writing, signed by me. However, such revocation shall not affect any disclosures already made in compliance with my prior consent. LLCEA/PS provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Patient Signature

Date

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