..  Patient Registration Form
NorthStar Surgery Specialists






Patient Registration Form

Today Date.:
PCP.:

PATIENT INFORMATION

   Personal Details:

Patient's Last Name:
First Name:
Middle Name:
Marital Status (Circle One):   Single    Mar    Div    Sep    Wid  
Email:
Date of Birth:
Age:
Sex: Male    Female
Street Address:
Sequrity No:
Home No:
City
State
ZIP Code
Cell Phone No
Occupation:
Employer:
Employer PhoneNo:
Prefered Languages:   English    Spanish    Other   
Ethnicity:  Hispanic or Latino    Not Hispanic or Latino   
Race:   American Indian or Alaska Native    Asian    Black or African American
   Native Hawaiian or Other Pacific Islander    White   
Gender Identity:   Male    Female    Transgender Male    Transgender Female   
Genderqueer    Other    Decline to Answer   
Sexuality:   Heterosexuail    Homosexuial    Bisexuial    Something else   
Dont Know    Decline to Answer   

INSURANCE INFORMATION

(Please give your insurance card to the receptionist.)

Name of Primary Insurance:
Policy Holder Name
Policy Holder S.S. #
Birth Date:
Group #
Policy #
Patient Relations to Subscriber:  Self   Spouse   Child   Other  
Employer:
Employer Address:
Employer Phone #:
Name of Secondary Insurance (If Applicable):
Subscriber Name:
Group #
Policy No
Patient Relations to Subscriber:   Self   Spouse   Child   Other  

I, the undersigned authorize payment of medical benefits to Northstar Surgery Specialists, P.A. for any services furnished me by the physician.
I understand that I am financially responsible for any amount not covered by my contract.
I also authorize you to release to my insurance company or their agent information concerning health care, advice, treatment or supplies provided by me.
This information will be used for the purpose of evaluating and administering claims of benefits.

Parent/Guardian Signature:
Date:

ADDITIONAL INFORMATION


1. In case of an Emergency, Please Notify :

Name:
Phone Number:
Relationship to Patient:
May we inform this person of confidential information?  YES    NO  
Name:
Phone Number:
Relationship to Patient:
May we inform this person of confidential information?  YES    NO  

2.Can Confitenial Messages be left on you:

Home Telephone Answering Machine?    YES    NO  
Call phone VoiceMail:   YES    NO  
Work VoiceMail:    YES    NO  
Personal Email:   YES    NO  
3. Do you have a Living Will?  YES    NO  
4. Do you have a medical Power of Attorney?   YES    NO  
if yes then ,  Name
Number
5. Pharmacy Information: 

Preferred Pharmacy:
Pharmacy Phone #:
Pharmacy Address:

Acknowledgement of Notice of Privacy PRACTICES & CANCELLATION POLICY


I have reviewed the Notice of Privacy Practices of NorthStar Surgery Specialists, P.A., which explains in plain language how my protected health information (PHI) will be used and disclosed, my individual rights, and the practice’s legal duties with respect to my PHI. I understand that I am entitled to receive a copy of this information upon request.

I also acknowledge the following cancellation/no show policy: New patients that no show to a scheduled appointment are subject to a $50 no show charge. Established/post-operative patients are subject to a cancellation/reschedule/no show charge of $50 if a 24 hour notice is not given, 7 day notice must be given to cancel/reschedule surgery, if 7 day notice is not given, you are subject to a $250 cancellation fee.

Signature:
Date:

Relase of Medical Records

I am requesting that the medical information be transferred to Vineet Choudhry MD.
I understand that the information in my or my child’s health record may include information relating to STD, AIDS, or HIV. It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

Signature:
Date:

Medical History Form

Today Date:
Date of Birth:
Sex: M    F   
Height
Weight
Primary Care Physican:
Reffering Physican:
Address
Address

Chief Complaint/Purpose of Visit:

Medical History-

Please List all the Current and Past Medical Conditions

None    Heart Disease   
COPD/Emphysema/Bronchitis    Other   
Previous Heart Attack  
Heart Wave Disorder   
Heart Rhythm Problem   
High Blood Pressure   
History of Stroke   
High Cholestrol   
Gallbladder Disease    Diabates   
Bowl Disease    Kidney Disease   
Stomach Ulcer    Aneima    Arthritis   
Thypiod    Vascular Disease   

Please list any pertinent descriptions, if needed, of any above conditions checked:

Surgical History - Please list Previous Operations and the year when they were performed: None  

Gallbladder Alterybypass Thyriod
Appendix HeartSurgery LungSurgery Tonsillectomy Biopsy
Stomach JointSurgery PlasticSurgery
Rectal
C-section SkinSurgey
Other

Medications- Please list all medications you are taking:   None  

Allergies- Please list any allergies to medications below: None   Latex  

Social History
W   S   Sep  

Do you have children??   Y   N  
Do you Smoke or Chew Tobacoo:  Never   Chew   Smoke   Former Smoker  
Have you tried to quit?  Yes NO
Do you use illiclit drugs?   Yes No
Do you Drink Alcohol?  Yes No
Occupation:
Family History-

Does anyone in your family have any of the following?

None    Heart Disease   
COPD/Emphysema/Bronchitis    Other   
Previous Heart Attack  
Heart Wave Disorder   
Heart Rhythm Problem   
High Blood Pressure   
History of Stroke   
High Cholestrol/ Lipids   
Gallbladder Disease    Diabates   
Bowl Disease    Kidney Disease   
Stomach Ulcer    Aneima    Arthritis   
Thypiod    Vascular Disease   
Will you absolutely refuse blood transformation at any condition?  Yes No
X-RAYS/LABWORK DONE:  Never YES
Are your Imune System is UptoDate  Yes No

Are you currently being treated by a physician for any of the following? Please check the box if “Yes.”

Please explain any “Yes” answers at the bottom of this page
General:
Weightloss   Weightgain    Fiver/Chills  
Gastrointestinal:

Diarrhea   Blood in stool    Abdominal pain   Heartburn   Constipation   
Neurologic:
Headache   Weakness    Dizzyness   Numbness/tingling  
Eyes:
Glaucoma   Cataracts    Recent vision changes  
Cardiovascular:
Chest pain   Irregular Heartbeat    Shortness of breath   Feet / leg swelling   Varicose veins  
Urinary:
Painful urination   Slow/frequent urination    Infections   Blood in urine   Kidney stones  
Psychiatric:
Depression   Trouble sleeping    Schizophrenia   Alcohol dependency   Drug dependency  
Respiratory:
Cough   Trouble breathing    Wheezing   Pneumonia  
Women Only:
Lap Pap Smear
Number of pregnancies  
Number of deliveries   
Venereal disease   Menstrual irregularities   Vaginal discharge   
Breast:
Last mammogram
Monthly self exams   Lumps    Nipple discharge   Pains  
EAR/NOSE/MOUTH/THROAT:
Hearing loss   Nose bleeds   Gum problems   Sore throat   Hoarseness   Trouble swallowing  
Hematologic/Lymphatic:
Easy bleeding or bruising   Anemia  
Blood transfusion:
Immunologic:
HIV / AIDS   Hepatitis (A, B, or C?)  
SKIN:
Rashes / dermatitis   Changes in moles  
Musculoskeletal:
Fractures/dislocations   Muscle pain/cramps  
MEN ONLY:
Last Prostate Exam (YR):
Last PSA Test (YR):
Prostate disease   Testicular lumps, pain   Venereal disease  

Please explain any “Yes” answers below:


Credit Card on File Policy

Please complete this form in its entirety. This form serves as confirmation that you are aware that Northstar Surgery Specialists P.A. has a policy that requires each patient to follow a payment plan with a credit card on file. I,hereby consent to follow the payment agreement given below with strict abidance. Should I have any difficulty, I fully accept it as my responsibility to report this matter to Northstar Surgery Specialists before my next payment, so as to allow for alternate arrangements to be made. This policy is in effect due to
the raise in patient deductibles and patient responsibility due to the change in health insurance policies and guidelines. If you have any questions about your coverage,
please contact your insurance company on the number listed on the back of your insurance card. If surgery is required, a cost estimation will be provided to you prior to surgery upon request The benefit of this form is that no cost will be collected up front prior to surgery. By signing below, this allows us to set you up on a payment plan
of $100/month for any and all charges incurred from office visits and operations. If you decline to put your card on file, you will be responsible for paying your
amount due in full PRIOR TO SERVICES, unless alternate payment arrangements have been agreed upon by
the billing administrator of NorthStar Surgery Specialists,P.A.

Patient Name: Date of Birth: Email:

YOU WILL RECEIVE A CONFIRMATION EMAIL PRIOR TO ANYTHING BEING CHARGED ON YOUR CREDIT CARD

The below credit card will be used for any charge incurred from office visits/operations. This card will be set up for a payment plan of $100/month after insurance’s final determination unless otherwise specified (defaults to the 1st day of every month unless otherwise specified)

Patient Name: Date of Birth: Email:
Sign:
Date:
Or

I decline to put my card on file, with the understanding that will be responsible for payment in FULL of any balance prior to any procedure performed/office visit.

Sign:
Date: