New Patient Registration

ASSIGNMENT OF BENEFITS

I HEREBY ASSIGN ALL MEDICAL AND/OR SURGICAL INSURANCE BENEFITS OTHERWISE DUE ME TO ARTURO QUINTANILLA, MD, FOR ALL, SERVICES RENDERED BY HIM. I UNDERSTAND THAT IAM FINANCIALLY RESPONSIBLE FOR ALL CHARGES, WHETHER OR NOT COVERED BY SAID INSURANCE. I ALSO AUTHORIZE SAID ASSIGNEE TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENTS. IF COLLECTION ACTION BECOMES NECESSARY TO COLLECT BALANCE DUE, I WILL PAY ANY COLLECTION COSTS AND/OR ASSOCIATED ATTORNEY FEES. ALSO, I HAVE RECEIVED, UNDERSTAND AND ACCEPT THE PRACTICE POLICIES STATEMENT FROM ARTURO QUINT ANILLA, MD

MINOR/CHILD CONSENT FORM

I am the parent, guardian, or personal representative of (Please input Name below)

and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the doctor and practice staff to perform necessary services for the child named above, including but not limited to x-rays, and treatment, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered and regardless of where that treatment is provided. This authorization is made under family code 6910.

Welcome to our practice. We intend to provide you with the care and service that you expect and deserve. Achieving you best possible health requires a"partnership" between you and your doctor. As our"partner in health", we ask you to help us in the following ways:

Schedule Visits with My Doctor for Routine Physical Exams and Other Recommended HealthScreening

I understand that my doctor will explain to me which regular health screenings are appropriate for my age, gender and personal and family history. I understand I will need to complete these recommended health screenings (immunizations etc. These health screenings are tests that can help detect life-threatening diseases and conditions. If I visit my doctor only for treatment for immediate problems and forget to arrange for regular health screenings, I put myself at risk of letting serious health problems go undetected. I will schedule regular visits with my doctor to complete my physical exam and to discuss these health screenings.

Keep Follow-up Appointments and Reschedule Missed Appointments

I understand that my doctor will want to know how my condition progresses after I leave the office.Returning to my doctor on time gives him or her chance to check my condition and my response to treatment. During a follow-up appointment, my doctor might order tests, refer me to a specialist, prescribe medication, or even discover and treat a serious health condition. If I miss an appointment and don't reschedule, I run the risk that my physician will not be able to detect and treat serious health condition. I will make every effort to reschedule missed appointments as soon as possible.

Call the Office When You Do Not Hear the Results of Labs and Other Tests

I understand that my physician's goal is to report my lab and test results to me as soon as possible.However, if I do not hear from my physicians' office within the time specified, I will call the office for my test results.

Inform My Doctor if I Decide Not to Follow His or Her Recommended Treatment Plan

I understand that after examining me, my doctor may make certain recommendations based on what he or she feels is best for my health. This might include prescribing medication, referring me to a specialist, ordering labs tests, or even asking me to return to the office within certain period of time. I understand that not following my treatment plans can have serious negative effects on my health. I will let my doctor know whenever I decide not to follow his or her recommendations so that he or she may fully inform me of any risks associated with my decision to delay or refuse treatment.

Thank you for your partnership. As our patients, you have the right to be informed about your health care. We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have. If you need more information about your health or condition, please ask.

Initial History Questionnaire

HOUSEHOLD

Please list all those living in the child's home.

During pregnancy, did mother

General DK= don't know

Biological Family History DK= don't know

Have any family members had the following?

Past History