New Patient Information and Consent New Patient Information and Consent Your confidentiality and privacy are important to us. Are you new to our medical services?Then please go ahead and register by filling the short form below. Please enable JavaScript in your browser to complete this form.Patient Information *FirstMiddleLastBirth Date *Age *Birth Gender *MaleFemaleMailing Address *Apt/SuiteCity, State, Zip Code *Primary Phone *Email Address *Emergency ContactEmergency Contact Phone NumberInsurance Provider *Policy Number/Member ID *Reason for visit? *May we leave testing results or referral info in email or voicemail? *YesNoAuthorization for Release of InformationI have reviewed a copy of the Notice of Privacy Practice and Financial Policy Notice below and... *Yes, I AgreeNo, I Do Not Agree1. 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