15005 Shady Grove Road, Suite 240, Rockville, MD 20850
+1 301-217-0979
info@shadygrovemedicine.com
Home
COVID-19 Testing
Services
Primary Care
Immediate Care
Weight Management
Health Screenings
Travel Health
Occupational Health
Cosmetic Services
Nutritional Supplements
Telehealth Appointments
Patient Portal
Patient Portal Login
About Our Office
About Us
Doctors
John Chuke, MD MHS
News: Washingtonian Article
Pricing
New Patient Registration
FAQ
Glossary
Contact Us
Home
COVID-19 Testing
Services
Primary Care
Immediate Care
Weight Management
Health Screenings
Travel Health
Occupational Health
Cosmetic Services
Nutritional Supplements
Telehealth Appointments
Patient Portal
Patient Portal Login
About Our Office
About Us
Doctors
Pricing
New Patient Registration
FAQ
Glossary
Contact Us
✕
New Patient Form
New Patient Information and Consent
Please enable JavaScript in your browser to complete this form.
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?
*
Yes
No
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.
Submit