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New Patient Registration Form

General

Please Note: Fields in red are required.
Female Male
Yes No
Single Married Widowed Divorced Other
English Spanish Other
Employment
Full-time Part-time Retired Self-employed Unemployed Disabled Minor
Person Responsible for Bill
Same as Patient Parent/Guardian* Other*

*If other than patient please fill in the following information*

Full-time Part-time Retired Self-employed Unemployed Disabled

Insurance

Same as Patient Spouse Parent/Guardian Other:

*If other than patient please fill in the following information*

Full-time Part-time Retired Self-employed Unemployed Disabled

*If other than patient or primary insurance subscriber please fill in the following information*

Full-time Part-time Retired Self-employed Unemployed Disabled

I hereby authorize my provider to furnish my insurance company or its representative or permit my insurance company or its representative to review any information requested with respect to any illness or accident, medical history or copies of hospital and medical records. A photostatic copy of this authorization shall be considered as valid as the original. I hereby authorize payment directly to my provider for this illness or injury, of the provider’s benefits otherwise payable to me, but not to exceed my indebtedness to said provider. I agree to pay the provider for all my charges whether or not covered by this assignment. The responsible party hereby agrees that the provider’s office or the party responsible for the billing of these services may check credit with any source to obtain credit information. I authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services. This release may include information which may be considered a communicable or venereal disease which may include, but are not limited to diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS). I understand all of the above and hereby state that the information is correct to the best of my knowledge. My signature indicates that I have read the above and grant the request of authorizations. I have been notified that I may receive services from the Advanced Practice Provider at this location.

I have been notified that I may receive services from the Advanced Practice Provider at this location.
PLEASE NOTE: The patient portion of the bill is due at the time of service unless prior arrangements have been made.
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Salina Regional Health Center Authorization to Verbally Release Protected Health Information & Emergency Contact list

I authorize Salina Regional Health Center, and all affiliates, health care providers to provide verbal information concerning my health care to those that I have listed below while I am a patient. Verbal requests for information from other friends, family, caretakers, concerning my health care will not be disclosed without an additional authorization from me. (Exception: Health Information may be disclosed without authorization in an emergency situation or if SRHC determines that the disclosure is in my best interest and the information disclosed is limited to those persons involved in my care).

Emergency Contact
Yes No

Additional Contact 1
Yes No
Yes No

Additional Contact 2
Yes No

Additional Contact 3
Yes No
I may revoke this authorization at any time by notifying my nurse. I have read the above and authorize verbal disclosure of my medical condition. I understand that treatment is not conditioned upon the execution of this authorization. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed and no longer protected by those regulations.
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(Note: Any requests for restriction/communication accommodation should be forwarded to the Privacy Office for approval on the "Request for Disclosure Restriction/Communication Accommodation Form")

Health History

Personal Medical History (check all that apply)

HEENT
Endocrine
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Hematology/Oncology
Infectious Disease
Integumentary
Neurologic

Other Medical History:

Surgical History
Surgery Year Surgery Year

Social History
No Yes drink(s) per week
No Yes
No Yes Former
Family Medical History
Relative Health Issues Age & Cause of Death
Mother
Father
Sibling
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other

Prescription and Non-Prescription Medication List

Medication Name Dosage How often do you take? What is the medication for? Prescribing Provider

Medication Allergies

Medication Name Reaction

Thank you for choosing Salina Pediatric Care as the source of your child's healthcare. To help us get to know your child, please take a few minutes to answer the following questions.

No Yes
No Yes
No Yes
No Yes
No Yes

Family History

Is there a family history of any of the following? (please list child's parents, grandparents, siblings, aunts, uncles and cousins):
No Yes Relation
Deafness/Hearing Problems No Yes
Nasal Allergies No Yes
Asthma or Wheezing No Yes
Tuberculosis No Yes
Heart Disease - Heart Attacks, Strokes or Hardening of Arteries prior to age 50 No Yes
High Blood Pressure prior to age 50 No Yes
High Cholesterol No Yes
Anemia No Yes
Bleeding Disorders No Yes
Liver Disease No Yes
Kidney Disease No Yes
Diabetes prior to age 50 No Yes
Bed-Wetting after age 10 No Yes
Epilepsy or Convulsions No Yes
Alcohol Abuse No Yes
Drug Abuse No Yes
Mental Illness No Yes
Mental Retardation No Yes
Immune Problems, HIV or AIDS No Yes
Thyroid Disease (High or Low) No Yes
Sickle Cell Disease No Yes
Sudden Infant Death Syndrome (crib death) No Yes
Cystic Fibrosis No Yes
Autism No Yes
Birth Defects or Abnormalities No Yes

Additional Information