New Patient Packet

Dear Valued Patient,

We are pleased that you have chosen to partner with us in the care for your health. However, in order to insure that you receive the best care possible and are taken care of in the most efficient way, we ask that you review the following office policies.

Healthcare Compliance:

We ask that you make an effort to comply with the physician's recommendations regarding routine follow-ups, medications, specialist referrals, procedures and etc.

Pain Management:

Please note that a referral will be made to a pain management specialist for chronic pain management medication at the discretion of Dr. Hill.

Prescriptions:

Prior to your office visits, please make a note of any refill needed.
For refills we ask that you contact your pharmacy and have them fax us a refill request, allowing 24-48 hours for it to be processed and forwarded back to the pharmacy.
Mail-Order prescriptions can be called in to the office and then picked up from the front desk. We no longer fax prescriptions to mail-order pharmacies. Again please allow 24 to 48 hours for processing.
Prescriptions for controlled substances cannot be called in or faxed to the pharmacy, but can be picked up at the front desk or at your scheduled appointment.

Lab/Imaging/Sleep study Follow up Policy:

To go over any results for labs, imagining or sleep studies you will need to make an appointment. If no appointment is made and there are abnormal results we will contact you to make an appointment to go over the results.

Cancellations/ No Show policy:

Time has been specifically reserved for your physician appointment, procedure or treatment. Please call at least 24 hours ahead to cancel your appointment. There will be a $25 charge if you fail to show up for a scheduled appointment or cancel with less than 24 hours' notice.

I hereby expressly acknowledge the receipt of West Volusia Family and Sports Medicine's Notice of Privacy Practices.

Patient Information

Name

Date of Birth

Social Security Number

Mailing Address

Email Address

City

State

Zip

Home Telephone Number

Mobile Telephone Number

Marital Status

Sex Male Female

Primary Policy Holder

Name

Date of Birth

Social Security Number

Mailing Address

City

State

Zip

Telephone Number

Marital Status

Relationship to Patient

Sex Male Female

Primary Insurance

Company Name

ID#

Group#

Secondary Insurance

Company Name

ID#

Group#

Policy Holder

Relationship to Patient

Employment Information

Employer

Phone

Occupation

Emergency Contact/Notification of Kin - Someone not in household

Name

Relationship to Patient

Telephone Number

Dr. John Hill and/or staff may discuss my medical conditions with the following people:

Name

Relationship to Patient

Telephone Number

Name

Relationship to Patient

Telephone Number

Name

Relationship to Patient

Telephone Number

Release of Information / Assignment of Benefits

I authorize the release of any medical information necessary to process my insurance claim. I authorize and request payment of medical benefits directly to my physicians. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me; I understand and agree that regardless of my insurance status I am responsible for any balance of my account.

I Agree to the Release of Information / Assignment of Benefits

Health History Questionnaire

All questions contained in this questionnaire are protected by privacy acts under HIPAA and will become part of your medical record. Fill in the blanks or check appropriate answers.

Personal Health History

Childhood Illnesses:

Measles

Mumps

Rubella

Chickenpox

Rheumatic Fever

Polio

Vaccination History

Tetanus or TET/DIP

Date

Influenza

Date

Hepatitis (series of 3)

Date

Pneumonia

Date

MMR (Measles, Mumps, Rubella)

Date

Chickenpox/Shingles

Date

List any medical problems that other doctors have diagnosed or check applicable items on list.

Surgeries and procedures (Please fill in any that applies):

Carotid Endartectomy ( remove plaque from neck vessels)

Thyroidectomy

Cardiac Catheterization. Stent

Coronary Artery Bypass: # of Vessels:

Pacemaker Automatic Implanted Defibrillator

Aortic Aneurysm Repair

Vascular Bypass: Specify Location:

Breast Surgery: Mastectomy Lumpectomy Biopsy (non-cancer)

Chest Surgery

Kidney Surgery

Hip Replacement: Left Right

Knee Replacement: Left Right

Amputations:

Endoscopy of Esophagus/ Stomach/ Duodenum (EGD)

Cholecystectomy (Gallbladder Removed)

Gastric Bypass: Type:

Appendectomy

Hysterectomy: Abnormal Vaginal (this is uterus only, see below)

Ovaries and Tubes: Left Right

Tubal Ligation (sterilization)

Bladder: Specify what type:

Prostate: TUNA TURP Other:

Cataracts: Left Right

Plastic Surgery: Specify:

Other:

Testing in the last two years:

DEXA Bone Scan for Bone Mass

Nuclear Medicine Scan

Hospitalizations Within The Last 2 Years

Date

Reason

Hospital

Date

Reason

Hospital

Date

Reason

Hospital

Have you ever had a blood transfusion? Yes No

If yes, what year?

Have you ever had radiation therapy? Yes No

If yes, indicate reason:

Have you ever had a blood clot in your lungs or legs? Yes No

If yes, what year?

Allergies or intolerance to Medications?

Please list the drug and make sure you are specific about your reaction. List your prescribed drugs and over-the counter drugs, such as vitamins and inhalers, eye drops and nasal sprays.