Fillable Patient Registration Form (ProHealth Professional Services)

Fill Online, Printable, Fillable, Blank Patient Registration Form (ProHealth Professional Services) Form

Use Fill to complete blank online PROHEALTH PROFESSIONAL SERVICES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Patient Registration Form (ProHealth Professional Services)

On average this form takes 131 minutes to complete

The Patient Registration Form (ProHealth Professional Services) form is 6 pages long and contains:

  • 5 signatures
  • 34 check-boxes
  • 490 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your ProHealth Professional Services forms online.

BROWSE PROHEALTH PROFESSIONAL SERVICES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Patient Registration Form
Date/Fecha: _____/_____/______ Reason for visit/Razon por visita:____________________
Name/Nombre:________________________ _____________ Social Security/Seguridad Social:_________________
Street Address/Domicilio:____________________________ Birth Date/Fecha De Nacimiento: _________________
City/Cuidad:_______ State/Estado:_____ Zip/Codigo Postal:_________ Age/Edad: _____ Sex/Sexo: ☐M ☐F
Home Phone #/Numero de Casa:________________ Cell Phone #/Numero de Celular:___________________
Cell Carrier/Compania de Cellular:_______________ DL#/Numero de Licencia:__________________
Occupation/Ocupacion: _______________________ Email: _________________
Marital Status/Estado Civil: ☐ Single ☐ Married ☐ Divorced ☐ Widowed
Emergency Contact Name/Contacto de Emergencia: _________________ Relation/Relacion:____________
Emergency Contact Phone #/Numero de Contacto:__________________
Employer Name/Nombre de Empleador: __________________ Department/Departamento:_____________
Employer Phone #/# de Empleador:______________________
Business Street Address/Direccion de Empleador:________________________________
City/Cuidad:____________________ State/Estado:_____ Zip/Codigo Postal:_________
Supervisor Name/Nombre del Supervisor:________________ Supervisor Email:_____________________
Supervisor Phone #/Telefono de su supervisor:___________________ Employee #:___________
Is your private insurance or employers workers compensation insurance responsible for your visit?
Quien es responsable para su cita hoy? Su insurancia privada? O la insurancia del empleador?
☐Private Insurance / ☐Employer Workers Comp Insurance / Name of insurance:_____________
Patient Information/Informacion de paciente
Patient Employer Information
Insurance
ProHealth
Occupational Medical Group
Patient Medical History
Patient Name/Nombre:_______________________ Date/Fecha:__________________
Patient Signature/Firma:_____________________ Account #:___________________
Please check your symptoms
Constitutional
Yes
No
Yes
No
Neurological
Yes
No
Genitourinary
Yes
No
Change in appetite
Headache
Discharge
Chills
Weakness
Frequent Urination
Fatigue
Numbness
Nighttime Urination
Fever
Poor Balance
Painful Urination
Sweats
Tingling
Skin
Weight loss
Musculoskeletal
Easy Bruising
Eyes & Vision
Joint Pain
Rash/itching
Blurred/Double
Muscle Pain
Skin Sores
Glasses/Contacts
Swelling
Endocrine
Eye Discharge
Hematologic
Excessive Hunger
Eye Pain
Frequent Infections
Excessive Thirst
Respiratory
Swollen Glands
Heat/Cold
intolerance
Congestion
Immune System
Cough
Allergies
Psychiatric
Shortness of Breath
Anxiety/nerves
Wheezing
Depression
Yes
No
Does your family have any of the following?
Cancer or Leukemia
☐ Father
☐ Mother
Diabetes:
☐ Father
☐ Mother
Heart Disease:
☐ Father
☐ Mother
High Blood Pressure
☐ Father
☐ Mother
Strokes:
☐ Father
☐ Mother
Yes
No
Do you use alcohol, drugs, or smoke?
Tobacco Use: How much? _____ Week
Alcohol Use: How much? _____ Week
Drug Use: Describe drug & use: ____________
Yes
No
Are you employed?
How long employed? _______
Position? _________________
Yes
No
Menstrual History
Are you pregnant?
Last menstrual date?
Last pap smear date?
Left or right handed? ☐Left ☐Right
Last tetanus shot date? ___________
Yes
No
List allergies you have:
Allergies (specify)
Yes
No
List medications you take:
Medications (specify)
1.
2.
Yes
No
Do you have any of the following?
Cancer (specify type):
Asthma
Heart Disease(CAD)
Stroke (CVA)
Depression/Anxiety
Diabetes
Hypertension
Other:
Yes
No
Have you had Surgeries or Operations?
Specify:
ProHealth
Occupational Medical Group
click to sign
signature
click to edit
Historia Medica De Lastimadura
Patient Name/Nombre:_______________________ Date/Fecha:__________________
Patient Signature/Firma:_____________________ Account #:___________________
Please check your symptoms
Constitucional
Si
No
Cardiovascular
Si
No
Neurologico
Si
No
Genitourinary
Si
No
Cambio en apetito
Dolor/Precion de pecho
Dolor de Cabeza
Desecho
Escalofrio
Desmayos
Mareos
Orinafrecuentemente
Fatiga
Latidos irregulars
Adormecimiento
Orina por la noche
Fiebre
Gastrointestinal
Problemas Equilibrio
Dolor cuando orina
Sudores
Dolor Abdominal
Hormigueo
Piel
Perdida de peso
Estrenimiento
Debilidad
Moretea facilmente
Ojos y Vision
Diarrea
Musculoesqueletico
Zarpullido/Comezon
Borrosa o doble
Nausea
Dolor en las coyunturas
Rojez
Lentes/Contactos
Vomito
Dolor de musculo
Llaga en la piel
Secrecion Ocular
Oidos, Nariz,
Garganta
Hinchazon
Sistema
Endocrino
Dolor en el ojo
Mareos
Sistema
Inmunologico
Hiper/
hipotiroidismo
Respiratorio
Dolor de oido
Fiebre del heno
Congestion
Congestion nasal
Alergias
Intolerancia
Tos
Secrecion Nasal
Hematologica
Psiquiatrico
Falta de aliento
Estornudos
Infecciones frecuentes
Ansiedad/ Nervios
Resollar
Dolor de Garganta
Hinchazon de glandulas
Depresion
Si
No
Does your family have any of the following?
Enfermedades de la sangre
☐ Padre
☐ Madre
Cancer or Leucemia
☐ Padre
☐ Madre
Diabetes:
☐ Padre
☐ Madre
Enfermedades del Corazon:
☐ Padre
☐ Madre
Alta Precion:
☐ Padre
☐ Madre
Ataque Fulminante:
☐ Padre
☐ Madre
Enfermedad Mental:
☐ Padre
☐ Madre
Si
No
Consume Alcohol, Usa Drogas, o Fuma?
Uso de Tobaco: Cuanto? _____ por semana
Consume alcohol: Cuanto? _____por semana
Usa Drogas: Describe el uso y tipo ____________
Si
No
Tiene Empleo?
Cuanto tiempo tiene trabajando? _______
Capacidad? _________________
Si
No
Ciclo Menstrual
Esta embarazada?
Fecha de ultimo ciclo menstrual?
Fecha de la ultima prueba de Papanicolaou?
Mano Dominante? ☐Zurdo ☐Derecho
Fecha de la ultima prueba de tetanus? ___________
Si
No
De que alergias padece
Allergias (especifique)
Si
No
List medications you take:
Medicamentos (especifique)
1.
2.
Si
No
Padece de lo siguente?
Cancer (Que tipo):
Asma
Enfermedad del Corazon
Ataque Fulminante
Deprecion/Ancieda
Diabetes
Diverticulitis
Hiperlipidemia
Hipertencion
Hipertiroidismo
Ulcera Peptica
Algun Otro:
Si
No
A tenido operaciones o sirugias?
Especifique:
ProHealth
Occupational Medical Group
click to sign
signature
click to edit
Consent For Medical Services And Financial Agreement
1. I attest that all information provided is correct to the best of my knowledge. I authorize the release of any medical information
necessary to proceed with my treatments and also to process my medical claims.
2. FINANCIAL DISCLOSURE: Dr. Soheil Younai has financial interest in this facility. If you or the provider have any objections, please
notify us so that we can refer you to other facilities.
3. INDEPENDENT MEDICAL PROVIDER: Your care at this facility will be managed by your doctor, surgeon, and other medical
providers, some of which are not employed by this center but have privileges to care for you at this facility. Although this medical facility
provides support for these independent healthcare providers, it neither dictates your care, nor is responsible for their actions. I
acknowledge and hold harmless this facility for any and all of my independent medical provider’s actions.
4.MEDICAL CONSENT: The undersigned consent authorizes any medical treatment, examination, Laboratory procedure, x-ray
examination, or physical therapy that may be considered advisable or necessary for the patient in the judgement of the attending
physicians.
5. FINANCIAL AGREMENT: The undersigned agrees, whether signing as a patient or agent, that in consideration of the services to be
rendered to the patient, the undersigned shall have the obligation to pay the account of the patient with ProHealth Valley
Occupational Medical Group in accordance with the Regular rates and terms of the ProHealth Valley Occupational Medical Group
as in effect. Such account shall be due and payable at the time of discharge unless other arrangements are approved in writing prior to
such arrangements. If the patient’s account is not paid when due it shall bear interest from the due date at the maximum for the account
of the patient on any deferred basis, and payment is not made when due ProHealth Valley Occupational Medical Group shall have
the immediate right to charge such sum to the credit cards of the undersigned listed hereon, the undersigned’s signature(s) herein
constituting complete authorization to ProHealth Valley Occupational Medical Group to charge such of credit cards. If the patient’s
account is referred to a collection agency and/or an attorney for collection, the undersigned shall pay all attorneys’ fees for costs of
collection.
6. MEDICARE: Patient’s Certification, Authorization to Release Information, and Payment Request: The undersigned certifies that the
information given in applying for payment under Title XVIII of the Social Security Act is correct. The undersigned authorizes any holder
of medical or other information about the patient to release to the Social Security Administration or its intermediaries or carriers any
information needed for this or any related Medicare claim. The undersigned requests that payment of authorized benefits be made on
the patient’s behalf.
7. RELEASE OF INFORMATION: ProHealth Valley Occupational Medical Group may disclose all or any part of the patient’s record
to any person or corporation which is or may be liable under a contract to ProHealth Valley Occupational Medical Group or to the
patient or to a family member or employer of the patient for all or part of the ProHealth Valley Occupational Medical Group charges,
including, but not limited to, hospital or medical service companies, workmen’s compensation carriers, welfare funds, or the patient’s
employer. All such information would be available after a written request and the approval of the attending physician.
8. RELEASE OF MEDICAL RECORDS: The undersigned authorizes the release of information in the patient’s medical records to
his/her private physician and to any physician, hospital, or agency to which ProHealth Valley Occupational Medical Group refers the
patient. The undersigned also authorizes any physician, hospital, or agency to which the patient is referred to the release of information
to ProHealth Valley Occupational Medical Group regarding treatment by said physician, hospital, or agency.
9.DISCLOSURE: The x-ray and physical therapy departments are owned and operated by ProHealth Valley Occupational Medical
Group. ProHealth Valley Occupational Medical Group bills for services provided by the Orthopedist and other Specialists performing
services in this clinic inclusive of the EMH nerve conduction studies.
10. INSURANCE ASSIGNMENT: The undersigned hereby authorizes payment directly to ProHealth Valley Occupational Medical
Group of any benefits payable to the patient including disability insurance and payment under Title XVIII of the Social Security Act,
which is applicable to the patient’s account. The undersigned understands that he/she is financially responsible to ProHealth Valley
Occupational Medical Group for the charges not covered by the patient’s insurance plan.
11. RELEASE FOR FUTURE CONTACT: The undersigned hereby authorizes ProHealth Valley Occupational Medical Group’s staff
to contact the patient for information relating to the patient’s medical condition.
The undersigned certifies that he/she has read the foregoing and is the patient, or duly authorized by the patient as patient’s general
agent to execute the above and hereby accepts its terms.
___________________________________ ___________________________________
Patient Signature Date
___________________________________ ___________________________________
Witness Date
ProHealth
Occupational Medical Group
Husband, Wife, Guardian or Nearest Relative, Or Person
Assuming Responsibility for the account
click to sign
signature
click to edit
Consentimiento para servicios médicos y acuerdo financiero
1. Doy fe de que toda la información proporcionada es correcta a mi leal saber y entender. Autorizo la divulgación de cualquier información médica
necesaria para continuar con mis tratamientos y también para procesar mis reclamos médicos.
2. DIVULGACION FINANCIERA: El Dr. Soheil Younai tiene interés financiero en esta instalación. Si usted o el proveedor tienen alguna objeción,
notifíquenoslo para que podamos derivarlo a otras instalaciones.
3. PROVEEDOR MEDICAL INDEPENDIENTE: Su atención en este centro será administrada por su médico, cirujano y otros proveedores médicos,
algunos de los cuales no son empleados por este centro pero tienen privilegios para cuidar de usted en este centro. Aunque este centro médico
proporciona apoyo a estos proveedores de atención médica independientes, no dicta su atención, ni es responsable de sus acciones. Reconozco y
eximo de responsabilidad a este centro por todas y cada una de las acciones de mi proveedor médico independiente.
4.CONSENTIMIENTO MEDICAL: El consentimiento suscrito autoriza cualquier tratamiento médico, examen, procedimiento de laboratorio, examen
por rayos X o fisioterapia que pueda considerarse aconsejable o necesario para el paciente en el juicio de los médicos asistentes.
5. AGREMENT FINANCIERO: El abajo firmante acuerda, ya sea firmar como paciente o agente, que, en consideración de los servicios que se
prestarán al paciente, el abajo firmante tendrá la obligación de pagar la cuenta del paciente con ProHealth Glendale Occupational Medical Group
de acuerdo con las tarifas regulares y los términos de la ProHealth Glendale Occupational Medical Group en vigor. Dicha cuenta deberá pagarse
en el momento de la aprobación de la gestión, a menos que se aprueben otros acuerdos por escrito antes de dichos acuerdos. Si la cuenta del
paciente no se paga cuando se vence, tendrá intereses a partir de la fecha de vencimiento en el máximo para la cuenta del paciente sobre cualquier
base diferida, y el pago no se hace cuando se ProHealth Glendale Occupational Medical Group tendrá el derecho inmediato de cargar dicha suma
a las tarjetas de crédito de los abajo firmantes enumerados en el presente documento, firma(s) del(los) abajo(s) que constituyen autorización
completa para ProHealth Glendale Occupational Medical Group para cobrar tales tarjetas de crédito. Si la cuenta del paciente es referida a una
agencia de cobro y/o a un abogado para el cobro, el abajo firmante pagará todos los honorarios de los abogados por los costos de cobro.
6. MEDICARE: Certificación del Paciente, Autorización para Divulgar Información y Solicitud de Pago: El abajo firmante certifica que la información
dada al solicitar el pago bajo el Título XVIII de la Ley de Seguridad Social es correcta. El abajo firmante autoriza a cualquier titular de información
médica u otra información sobre el paciente a divulgar a la Administración del Seguro Social o a sus intermediarios o transportistas cualquier
información necesaria para esta o cualquier reclamación relacionada de Medicare. El abajo firmante solicita que el pago de los beneficios
autorizados se realice en nombre del paciente.
7. RENUNCIA A LA INFORMACION: ProHealth Glendale Occupational Medical Group puede revelar todo o parte del registro del
paciente a cualquier persona o corporación que sea o pueda ser responsable bajo un contrato a ProHealth Glendale Occupational Medical
Group o al paciente o a un familiar o empleador del paciente por la totalidad o parte de los cargos de ProHealth Glendale
Occupational Medical Group, incluyendo, pero no limitado a, compañías de hospital o servicio médico, compañías de compensación de
trabajadores, fondos de bienestar o el empleador del paciente. Toda esta información estaría disponible después de una solicitud por escrito y la
aprobación del médico asistente.
8. RENUNCIA DE LOS RECORDADOS MEDICALES: El abajo firmante autoriza la divulgación de información en los registros médicos del paciente a su
médico privado y a cualquier médico, hospital o agencia a la que ProHealth Glendale Occupational Medical Group remita al paciente. El abajo
firmante también autoriza a cualquier médico, hospital u agencia a la que se remite al paciente a la divulgación de información a ProHealth
Glendale Occupational Medical Group con respecto al tratamiento por parte de dicho médico, hospital u agencia.
9.DISCLOSURE: Los departamentos de rayos X y terapia física son propiedad y son operados por ProHealth Glendale Occupational Medical Group.
ProHealth Glendale Occupational Medical Group factura por los servicios proporcionados por el Ortopedista y otros Especialistas que
realizan servicios en esta clínica, incluyendo los estudios de conducción nerviosa de EMH.
10. ASIGNAMIENTO DE SEGURO: El abajo firmante autoriza el pago directamente a ProHealth Glendale Occupational Medical Group de
cualquier beneficio pagadero al paciente, incluyendo el seguro de discapacidad y el pago bajo el Título XVIII de la Ley de
Seguridad Social, que es aplicable a la cuenta del paciente. El abajo firmante entiende que él / ella es financieramente responsable de ProHealth
Glendale Occupational Medical Group por los cargos no cubiertos por el plan de seguro del paciente.
11. RENUNCIA PARA EL CONTACTO FUTURO: El abajo firmante autoriza al personal de ProHealth Glendale Occupational Medical Group a ponerse
en contacto con el paciente para obtener información relacionada con la condición médica del paciente.
El abajo firmante certifica que ha leído lo anterior y es el paciente, o debidamente autorizado por el paciente como agente general del paciente
para ejecutar lo anterior y por la presente acepta sus términos.
___________________________________ ___________________________________
Firma del paciente Fecha
___________________________________ ___________________________________
Witness Date
Esposo, Esposa, Guardián o Pariente más Cercano, o
Persona asumiendo la Responsabilidad de la cuenta
ProHealth
Occupational Medical Group
Physician-Patient Arbitration Agreement
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered
under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by
submission to arbitration as provided by California law, and not by lawsuit or resort to court process except as California law provides for judicial
review of arbitration proceedings.
Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate
to treatment or service provided by the physician including any spouse of heirs of the patient and any children, whether born or unborn, at the
time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both mother and the
mother’s expected child or children.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners,
associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without
limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician
to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
However, following the assertion of any claim against the physician, any fee dispute, whether or not the subject of any existing court action, shall
also be resolved by arbitration.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an
arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties
within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the
expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not
including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators
have the immunity of a judicial officer from civil liability when acting in capacity of arbitrator under this contract.
This immunity shall supplement, not supplant, any other applicable statutory or common law.
Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in
a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending
arbitration.
The parties agree that provisions of California law application to health care providers shall apply to disputes within this arbitration agreement,
including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring
before the arbitrators a motion for summary judgement or summer adjudication in accordance with the Code of Civil Procedure. Discovery shall be
conducted pursuant to Code of Civil Procedure section 1283.05; however , depositions may be taken without prior approval of the neutral
arbitrator.
Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A
claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the
applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed
herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California
Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of
this agreement to apply to all medical services rendered any time for any condition.
Article 6: Retroactive Effect: If patient intends this agreement to cover services to cover services rendered before the date it is signed (including,
but not limited to, emergency treatment) patient should initial below:
Effective as of the date of first medical services ___________________________________
If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be
affected by the invalidity of any other provision.
I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION
AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
By: ______________________________ Date:___________ By: __________________________ Date:_____________
By:___________________________
_______________________________________
ProHealth
Occupational Medical Group
Patient’s or Patient Representative Initials
Physician’s or Authorized Representative’s Signature
Patient’s or Authorized Representative’s Signature
Print or Stamp of Physician Medical Group Association
Print Patient’s Name
A signed copy of this document is to be given to the Patient. Original is to be filed in Patient’s medical records. (2-08)
(If Representative, Print name and Relationship to patient)
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Patient Registration Form (ProHealth Professional Services)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document