Patient Registration Information

PATIENT'S PERSONAL INFORMATION

Marital Status:

Single Jarried Divorced Widowed

Sex:

Male Female

Name:

Last Name, First Name, Initial

Date of Birth:

Social Security #:

Home Phone:

Work Phone:

Cell Phone:

Address:

Apt. #:

City:

State:

Zip:

Race:

Ethnicity

PATIENTS/RESPONSIBLE PARTY INFORMATION

Relationship to Patient:

Self Spouse Child Other:

If Other:

Name:

Last Name, First Name, Initial

Date of Birth:

Social Security #:

Home Phone:

Work Phone:

Cell Phone:

Address:

Apt. #:

City:

State:

Zip:

Race:

Ethnicity

PHARMACY INFORMATION

Name:

Telephone:

Address:

City:

State:

Zip:

EMERGENCY CONTACT

Name:

Relationship:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

DO YOU HAVE AN ADVANCE DIRECTIVE? IF NOT, YOU MAY CONTACT A LAWYER TO HAVE ONE SET UP FOR YOU.

YES NO

ATTENTION PATIENT

Due to a limited space for appointments, we ask that you please give us a call ahead of time to either cancel or re-schedule any of your appointments. Any patient that schedules and does not show up for their office visit will be charged a $15.00 fee for failure to appear to any of your doctor's appointment. After carefully reading the above statement, with my signature below, I am agreeing to this no-show policy.

Assignment of Benefits • Financial Agreement

I hereby give authorization for payment of insurance benefits to be made directly to FAMILY CARE CLINIC, and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default I agree to pay all costs of collections, and reasonable attorney's fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that photocopy of this agreement shall be as valid as the original.

Date of Birth:

Your signature:

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

(Please Mail in Medical Records If More Than 10 Pages)

PATIENT INFORMATION

Name:

Date of Birth:

Address:

I HEREBY AUTHORIZE MY MEDICAL RECORDS TO BE RELEASED FROM:

Name of Doctor:

Address:

Telephone:

Fax:

REGARDING THE FOLLOWING INFORMATION FOR CONTINUITY OF CARE:

Laboratory Results

Radiology and Imaging Reports

Other Tests (Please Specify):

Entire Medical Records

Other:

I understand that the information used or disclosed pursuant to this authorization form may include information relating to HumanImmunodeficiency Virus (HIV)i or Acquired Immunodeficiency Syndrome (AIDS); treatment for or history of drug or alcohol abuse or mental or behavioral health or psychiatric care.

BY MY SIGNATURE, I AUTHORIZE RELEASE OF MEDICAL RECORDS:

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 or Qualified Personal Representative

Date of Birth:

I, (PLEASE INPUT NAME BELOW), give Dr. Toks Akinyeye MD permission to . release all medical information to the following people: (Please select a password to issue to the following people upon calling the office. Each person will be asked to verify this password before information can be released)

PASSWORD:

Add new row

I understand that this form is effective immediately upon signing and is valid unless I make changes.

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 Signature

Date of Birth:

Acknowledgement of Review of Notice of Privacy Practices

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 or Personal Representative

Date

Name of Patient or Personal Representative

Description of Personal Representative's Authority

CONSENT TO MEDICAL TREATMENT

I, or authorized representative acting on behalf of the patient, or as a parent or legal guardian of the patient, do hereby consent to receiving general medical services, which may include routine diagnostic procedures and such medical treatment by the physician, his assistants or his designees consider to be necessary in his judgment. I also acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to results of treatments or examination at Family Care Clinic.

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.

Signed:

Date

Relationship, if other than patient:

Witness:

Date

Your information will be encrypted.