New Patient Information and Consent

New Patient Form

New Patient Information and Consent

Patient Information *

First

Middle

Last

Birth Date *

Age *

Birth Gender *

Male
Female

Mailing Address *

Apt/Suite

City, State, Zip Code *

Primary Phone *

Email Address *

Emergency Contact

Emergency Contact Phone Number

Insurance Provider *

Policy Number/Member ID *

Reason for visit? *

May we leave testing results or referral info in email or voicemail? *

Authorization for Release of Information

I have reviewed a copy of the Notice of Privacy Practice and Financial Policy Notice below and... *

Yes, I Agree
No, I Do Not Agree

1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Shady Grove Internal Medicine and its associated physicians, clinicians, and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Shady Grover Internal Medicine.

2. I agree to be contacted via Phone, Email or SMS with information related to my visit, like a patient portal invitation, post-visit satisfaction survey, appointment or checkup reminders, health tips, or new services that relate to me or my family.

3. I consent to the use and disclosure of my/the patient’s protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment, and health care operations consistent with the Shady Grove Internal Medicine Notice of Privacy Practices.

4. I authorize payment of medical benefits to Shady Grove Internal Medicine physicians or their designee for services rendered.

5. I give permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.