Patient Registration Form

DEMOGRAPHIC INFORMATION

Last Name:

First Name:

MI:

Date of Birth:

Race:

Social Security #:

Ethnicity:

Address 1:

Address 2:

City:

State:

Zip:

Language:

Language Country:

Check if applicable

Pregnant

Nursing

Whom may we thank for referring you to our office?

CONTACT INFORMATION

Home Phone:

Work Phone:

Cell Phone:

Email address

EMERGENCY CONTACT INFORMATION

Contact First Name:

Contact Last Name:

Relationship to Patient:

Contact Home Phone

Contact Cell Phone:

Contact Address:

City:

State:

Zip:

FAMILY MEMBERS IN THE PRACTICE

Add Family Members:

PRIMARY CARE/OTHER PHYSICIAN

Physician Name:

Practice Name:

Address:

City:

State:

Zip:

Social Security #:

Work Phone:

Address of Person Responsible:

Pharmacy Name:

Pharmacy Phone:

Pharmacy Location:

By signing below, I attest that the information provided above is true and accurate

Signature of Insured / Guardian:

Date:

Financial Policy

Cole Surgical Arts participates with most insurance plans. However, each insurance policy is different, and it is difficult to know benefit details for all carriers. Contact your insurance company if you have any questions regarding benefits and payment obligations.

Copayments and Deductibles

All co-payments, co-insurance, and deductible amounts are due and payable at the time of service.

Returned Check

There is a $40.00 charge for returned checks.

Patients Without Insurance Coverage and Self-pay

Self-pay accounts are those covered by carriers the practice does not participate, patients without insurance, or patients who have not met their deductible.

Unpaid Balance

Unpaid balances over 90 days old, without payment arrangements, may be sent to collections. You will also be responsible for any additional amounts incurred for collecting past-due balances.Payment plans will incur interest.

Letters and Forms

As a courtesy to our patients, we fill out forms. However, we charge for the following:Letter or simple form (other than regular work/school excuse) - $10.00 per letter or simple form

Forms: FMLA, Short-term Disability, etc. - $20.00 Per set

Medical Record Release Fees

Requests for copies of medical records must be made in writing to the clinic. We will fax medical records to a provider of your choice free of charge. However, if you need a copy from us, you will be charged reasonable costs of reproducing the record as provided by applicable law.

Referrals

Some insurance carriers require referral from your primary care provider. If this authorization is not provided, you will be rescheduled or pay for your visit at the time of service.

If you have any questions or need clarification of any of the policies, please contact our business office.

I have read and I understand the above policy and agree to it in its entirety.

INSURANCE INFORMATION

Primary Medical Insurance

Insurance Company:

Co-Pay:

Group #:

Subscriber #:

Insured First Name:

Insured Last Name:

Social Security #:

DOB:

Relationship to Patient:

Address:

City:

State:

Zip:

Phone #:

Advanced Directive?

Yes No

Where is it filed?

Insurance Employed By:

Business Address:

City:

State:

Zip:

Business Phone #:

Is the patient covered by additional Insurance?

Yes No

Add Secondary Medical Insurance

Occupation:

Business Name:

Business Phone:

Drivers License #:

State Issued:

Is this an accident?

Yes No

Date of Injury

Is this a motor vehicle accident?

Yes No

YOUR INSURANCE CARD ANND PHOTO ID ARE REQUIRED AT THE TIME OF YOUR VISIT

By signing below, I attest that the information provided above is true and accurate.

Signature of Insured/Guardian:

Date:

No-Show Policy for Surgical and In-Office Procedures

At Cole Surgical Arts, we strive to provide the highest quality care to all our patients. To ensure that we can accommodate all individuals in need of surgical and in-office procedures, we have established the following No-Show Policy.

Definition of a No-Show

A "No-Show" occurs when a patient:

Fails to appear for a scheduled surgical or in-office procedure without prior notification.
Cancels or reschedules their appointment with less than 24 hours' notice (unless due to an emergency or extenuating circumstances).

Policy Guidelines

Surgical Procedures

Patients who do not show up for a scheduled surgical procedure without prior notice may be subject to a cancellation fee of $75.
Failure to provide at least 48 hours’ notice for surgical procedure cancellations or rescheduling may result in the inability to reschedule the procedure without a deposit.
Multiple no-shows for surgical procedures may lead to dismissal from the practice at the discretion of the provider.

In-Office Procedures

Patients who fail to appear for an in-office procedure without prior notice may be subject to a fee of $50.
A 24-hour notice is required for cancellation or rescheduling of in-office procedures.
Repeated no-shows for in-office procedures may lead to restrictions on scheduling future appointments.

How to Cancel or Reschedule

To cancel or reschedule an appointment, patients should contact our office at 256-273-4300 as soon as possible. If calling after business hours, please leave a detailed message including your name, appointment date, and reason for cancellation.

Exceptions

We understand that emergencies and unforeseen circumstances arise. If you are unable to attend your appointment due to an emergency, please notify us as soon as possible. Exceptions to this policy will be made on a case-by-case basis at the discretion of the provider.

We appreciate your cooperation in helping us provide timely care to all our patients. If you have any questions regarding this policy, please contact our office at 256-273-4300.

Thank you for choosing [Practice Name] for your surgical care.

No-Show Policy Agreement

At Cole Surgical Arts, we are committed to providing quality care to all our patients. To ensure that appointment slots are used efficiently, we have established the following No-Show Policy. Please review and sign this agreement to acknowledge your understanding and acceptance of our policy.

No-Show Policy

A "No-Show" occurs when a patient:

Does not appear for a scheduled surgical or in-office procedure without prior notification.
Cancels or reschedules their appointment with less than 24 hours’ notice for in-office procedures or 48 hours’ notice for surgical procedures (unless due to an emergency or extenuating circumstances).

Fees and Consequences

Surgical Procedures: A no-show or failure to cancel within 48 hours may result in a cancellation fee of $75 and/or the requirement of a deposit before rescheduling.
In-Office Procedures: A no-show or failure to cancel within 24 hours may result in a fee of $50.
Repeated no-shows may lead to dismissal from the practice at the provider's discretion.

Cancellation & Rescheduling

Patients must contact our office at 256-273-4300 as soon as possible to cancel or reschedule an appointment. If calling after business hours, please leave a detailed message including your name, appointment date, and reason for cancellation.

Acknowledgment & Agreement

have read and understand the No-Show Policy of Cole Surgical Arts. I agree to abide by the terms outlined above. I understand that failure to comply may result in fees and/or discharge from the practice.

Patient Name:

Date of Birth:

Patient Signature:

Date:

Witness (if applicable):

Date:

Thank you for your cooperation in helping us provide the best care for all our patients.

Authorization to Use and Disclose Protected Health Information

I authorize the use or disclosure of the above-named individual’s health information as described below to/from:

Cole Surgical Arts, PC
323 Medical Center Drive SW
Fort Payne, AL 35968

Agency or Individuals Authorized to release my Health Information to/from:

Treatment/ Ongoing medical care

Coordination of care

Doctor/Clinic/Hospital:

Address:

Telephone Number:

Fax Number:

Please release the following:

All Health Information

History/Physical Exam

Discharge Summary

Lab and path report(s)

Progress/Consultation Notes

Diagnostic Tests

Other (specify):

If other, specify:

I also consent to the specific release of the following records:

Drug, alcohol, substance abuse

Tests for HIV/AIDS/STD

Psychiatric/Mental Health

Genetic Testing

This authorization will expire 1 year after the date of signature below, unless earlier date is specified.I understand I have the right to revoke this authorization at any time, in writing, except where the disclosure has already been made.

A photocopy or facsimile of this authorization shall be considered as valid as the original.I have been advised of my right to receive a copy of this authorization.

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:

Print Name:

Relationship to Patient:

Witness Name:

Witness Signature:

Please fax records to 256-979-1017. If you have any questions, please call us at 256-273-4300.

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 of Patient (Legal Guardian)

Date:

Name of patient

Date:

CONSENT TO EMAIL OR TEXT USAGE FOR APPOINTMENT REMINDERS AND OTHER HEALTHCARE COMMUNICATIONS

Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or text address from the Practice.

Patient Initials

Cell Phone Number

I authorize to receive email/text messages for appointment reminders and general health reminders/feedback/information in the Patient Portal to the following Email Address:

*The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details.
*Reply HELP for support. Reply STOP to opt out.
*See our privacy policy for more information. https://www.colesurgicalarts.com/patient-policies

Signature

Date:

Print Name

Relationship to Patient

Pre-Admission Pre-Screening

What phone number does the Pre-Admit Nurse need to call for your phone interview?

Please provide a SECONDARY PHONE NUMBER if the nurse is unable to reach you:

Name:

Relationship:

Phone Number:

******Does the nurse have permission to obtain/discuss your health history and give instructions for your upcoming procedure with this person?

Yes No

Do you take any of the following medications?

Mounjaro/Zepbound/Tirzepatide

Yes No

Ozempic/Wegovy/Rybelsus/Semaglutide

Yes No

Other weight loss injection

Yes No

If yes, what medication:

Other weight loss oral medication

Yes No

If yes, what medication:

Other diet pill or injectable for weight loss

Yes No

If yes, what medication:

Who is your:

Primary Medical Doctor:

Location:

Cardiologist (heart doctor):

Location:

Neurologist:

Location:

Pulmonologist (lung doctor):

Location:

Do you have any upcoming appointments with any of your specialists?

When was your last cardiologist appointment?

Have you had?

EKG

ECHO/ultrasound of your heart

Stress Test

Add new row

Are you taking a blood thinner?

Yes No

Name of medication:

What doctor prescribes the blood thinner?

Patient History Form

Full Name:

Date:

Birth Date:

Age:

Primary Care:

Preferred Pharmacy:

ALLERGIES

NO KNOWN ALERGIES

Add Allergy

MEDICATIONS/SUPPLEMENTS

NO MEDICATIONS

Add Medications

SURGERIES

NO SURGICAL HISTORY

Add Surgeries

PERSONAL MEDICAL HISTORY

Other, specify:

FAMILY MEDICAL HISTORY

No significant Family history is known

Add new row

SOCIAL HISTORY

Current

Do you smoke cigarettes?

Yes No

Current: packs/day

# of Years

Past:

Quit Date:

Packs/day

# of Years

Other Tobacco: (check all that apply)

Pipe

Cigar

Snuff

Chew

E-cig/Vape

ALCOHOL/DRUG USE

Do you drink alcohol?

Yes No

Beer

Wine

Liquor

Do you use recreational drugs?

Yes No

If yes, what type:

# of times/week:

ADVANCED DIRECTIVE

I have an advanced directive

I do not have an advanced directive

FALL RISK ASSESSMENT

FALL HISTORY

Fall in the last year?

Yes No

Notes

Worries about falling when walking or standing?

Yes No

Notes

Feels unsteady when walking or standing?

Yes No

Notes

OTHER PROVIDERS/SPECIALISTS

Specialist:

Cardiology (Heart Doctor)

Gastoenerologist (GI)

OB/GYN

Neurology

Pulmonary (Lung Doctor)

Other

Add Providers/Specialist

Health Screening

Test

EGD (Upper Scope)

Colonoscopy

Other

Add Providers/Specialist

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