PATIENT INFORMATION:

Patient's Name:	(Last)		(First)		(Middle Initial)
Address:	(Street - NO P.O. Box Please)		(City)		(State)    (Zip Code)
Home Telephone:		Work Telephone:			Day Night (check one or both)
Date of Birth:	(Month)       (Day)          (Year)	Race:	(Required by MD Dept of Health)		Sex:  Male Female
S.S. Number:	--
Spouse's Name:			Work Telephone:
Emergency Contact:	(Not residing with patient)		(Relationship to patient)	Telephone:

PATIENT EMPLOYMENT:

Occupation:		Employer:
Supervisor:		Telephone:

MEDICAL INSURANCE:  "Please list the insurance provided through your employer as the Primary Insurance Company

Primary Care/Referring Doctor:		Telephone:
PRIMARY INSURANCE COMPANY:
Policy Holder's Name:			(Relationship to patient)
Patient's Policy No.:		Group:
Policy Holder's Birth Date:		Co-pay Amount:		(If applicable)
Policy Holder's Employer:		Employer's Telephone:
Do you or your spouse have other health insurance?	Yes No		If yes, please provide below.
SECONDARY INSURANCE COMPANY:
Policy Holder's Name:			(Relationship to Patient)
Patient's Policy No.:		Group:
Policy Holder's Birth Date:		Co-pay Amount:		(if applicable)
Policy Holder's Employer:		Employer's Telephone:

    By clicking below, I hereby certify that I (or my dependant) assign directly to Smith, Harne, & Song, M.D., P.A., all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges not paid by insurance, including late fees and collection expenses. Returned check fee is 35.00; late fee is 1.5%/month (18%/year); collection fees equal 30% of balance plus court fees and interest.

Agree   Disagree

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MEDICAL HISTORY: (List)

Any current or previous medical conditions?       

Any current or previous operations?       

Have you ever smoked?   Yes No     If yes, how much?

Do you drink alcohol?      Yes No     If yes, how much?

Any medical condition in your immediate or extended family?  

Allergies to medications or contrast (iv dye):	Current medications (include dose & how often):

General Medical History (please indicate if you or any family member have any of the following):

Heart disease:	Yes No	Family
Lung, thyroid, endocrine disease:	Yes No	Family
Hepatitis/liver disease:	Yes No	Family
Digestive/bowel problems:	Yes No	Family
Ear, nose, throat, mouth disease:	Yes No	Family
Muscle/bone disease:	Yes No	Family
Blood disease:	Yes No	Family
Transfusions:	Yes No	Family
Neurological/seizure disorders:	Yes No	Family
Psychiatric disorders:	Yes No	Family

 

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UROLOGIC HISTORY: (Please indicate if you have had any of the following)

Kidney stones or diseases:

Urinary infections:

Any voiding symptoms:

Blood in the urine (hematuria):

Loss of bladder control/incontinence:

If male:

Impotence:

If female

Are you pregnant?

Yes No

Date of last menstrual period: