Step 1 of 7 - Personal Information 0% PATIENT REGISTRATION INFORMATIONName* First Last Gender* Male Female Decline Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security # Marital StatusSingleMarriedDivorcedWidowedOtherContact InformationPrimary Phone Number*Additional (Home/Work) PhoneEmail Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Same as home address Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Race American Indian/ Alaska Native Asian Black/ African American White/Caucasian Other Race Other Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred LanguageEnglishSpanishOtherRESPONSIBLE PARTY INFORMATION*Statements will be addressed to Responsible Party*Responsible Party Information* Myself Someone else Patient Relationship to Responsible Party* For eg. Spouse, Child, Legal Guardian, ParentResponsible Party Name* First Last Gender* Male Female Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Responsible Party Home Address Same as myself Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Responsible Party Mailing Address Same as home address Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home/Work PhoneEmergency ContactEmergency Contact 1Emergency Contact Information Same As Responsible Party Full Name Phone Number Relationship PRIMARY INSURANCE CARRIERDo you have the primary policy Insurance?* YES NO Are you the main subscriber? YES NO Name of Subscriber* Patient Relationship to Subscriber* Policy Holder (Primary Subscriber)'s Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insurance Carrier Name* Policy ID # / SSN* SECONDARY INSURANCE CARRIERDo you have secondary insurance ?* YES NO Are you the main subscriber?* YES NO Name of Subscriber* Patient Relationship to Subscriber* Policy Holder (Secondary Subscriber)'s Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insurance Carrier Name* Policy ID # / SSN* I hereby grant permission for Dhansukh Patel M.D. P.C. to employ such medical, surgical, and x-ray procedures as my doctor may consider necessary in my diagnosis and treatment. I authorize the holder of medical or other information to release to my insurance carrier, governmental agency, or its intermediary ,any information needed for this or a related insurance claim. I agree to pay any charges incurred by me to Dhansukh Patel M.D. P.C. I HAVE READ AND UNDERSTOOD THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS.* I agree to grant permission mandatory sign is showing above the checkboxI hereby grant permission for Dhansukh Patel M.D. P.C. to employ such medical, surgical, and x-ray procedures as my doctor may consider necessary in my diagnosis and treatment. I authorize the holder of medical or other information to release to my insurance carrier, governmental agency, or its intermediary ,any information needed for this or a related insurance claim. I agree to pay any charges incurred by me to Dhansukh Patel M.D. P.C. I HAVE READ AND UNDERSTOOD THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS. Today's Date Signature of Patient or Legal Guardian* PATIENT HEALTH QUESTIONNAIREChief Complaint(Briefly describe your main reason for coming to the doctor today) Known Medical ProblemsPrevious Surgeries(include dates)Previous Hospitalizations(include dates) DK = DON'T KNOWDo you smoke or did you smoke? YES NO How much? How long? Do you drink alcoholic beverages? YES NO How often? Do you do or did drugs? YES NO what, when and route? Do you follow a particular diet? YES NO If so what) Do you exercise regularly? YES NO What kind ? How much ? Family History (please list any specific major health problems for each person listed below) Father Mother Brothers/Sisters Other Are you allergic to or have you had a reaction to any of the following Aspirin Codeine Local Anesthetics Iodine Penicillin Latex Amoxicillin Sulfa Metal Dairy Seasonal or Environmental Barbiturates Sedatives or Sleeping Pills Keflex/Cephalosporins Nuts Eggs Morphine Ibuprofen Naproxen None Others Select None if you dont have any.Other Allergies Pharmacy InformationName, Address & Phone Number Consent to Obtain External Prescription HistoryConsent to Obtain External Prescription History*I, authorize Dhansukh M.D. P.C. and Affiliated Providers to view my external prescription history via the RxHub Service. This prescription service allows providers to search all possible prescriptive medications that have been filled under my name and may include those current and discontinued in the past. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years. I agree to the above mentioned External Prescription History Consent to Use and Disclosure of Protected Health InformationConsent to Use and Disclosure of Protected Health Information*Use and Disclosure of Your Protected Health Information: Your protected health information will be used by Dhansukh Patel M.D. P.C. or disclosed to others for the purposes of treatment, obtaining payment or supporting the day-to-day health care operations of the practice. Notice of Privacy Practices: You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent. Requesting a Restriction on the Use or Disclosure of Your Information: You may request a restriction on the use or disclosure of your protected health information. Dhansukh Patel M.D. P.C. may or may not agree to restrict the use or disclosure of her protected health information. If Dhansukh Patel M.D. P.C. agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. Revocation of Consent: You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. Reservation of Right to Change Privacy Practices: Dhansukh Patel M.D. P.C. reserves the right to modify the privacy practices outlined in the notice. I have reviewed this consent form and give my permission to Dhansukh Patel M.D. P.C. to use and disclose my health information in accordance with it. I HAVE READ AND UNDERSTOOD THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS. I have read above conditions of treatment and payment and agree to their consent Consent for Insurance BillingConsent for Insurance Billing*I authorize the Dhansukh Patel M.D. P.C. to use my name on any and all claims or documents that relate to health insurance benefits due to me and my dependents. I authorize release of any information related to any claims to all my insurance companies or other relevant parties. I understand that I am responsible for my bill and agree to pay all charges for services and items provided to me. I authorize my doctor to act as my agent in helping me obtain payment from my insurance companies. This consent will be valid until termination of care provided under Dhansukh Patel M.D. P.C. I READ AND UNDERSTOOD THE SCOPE OF MY CONSENT. Office PolicyConsent for Office Policy*1)All co-pays and past due balances are expected at time of service, unless a prior agreement has been made with our billing department. 2)Please contact our office if you are running late as you may be asked to reschedule your appointment if you are more than 30 minutes late 3) Our office policy for a missed appointment is: If it is an appointment for a new patient, the appointment will be rescheduled once, further cancellations will result in termination Three (3) no-show appointments will result in dismissal from the practice $50 No Show fees will be applied if no notification is given to our office to reschedule or cancel your appointment 4) The following guidelines for dispensing medications in our office have been established: A) If you are on medications that requires refills for a chronic disease (for example, high blood pressure or diabetes), you will be given ample refills for 30 or 90 days or 180 days at a time during your office visit. i. When you are down to a 30 day supply of medication, we ask that you call and schedule your follow-up office visit in order to be evaluated and have your medications adjusted or refilled. We ask that you allow enough time for us to make an appointment so you’re not without your medication. B) For the safety and well-being of our patients, i. Requests for new medications (including antibiotics) and medication refills will not be taken over the phone or over the Internet during office hours without an appointment and evaluation by the physician. ii. No new medications (including antibiotics) will be called in over the phone after office hours by the on-call physician. iii. We understand that unexpected situations arise, thus a small refill of a chronic medication will be granted for one or two weeks after office hours on an as-needed basis determined by the on-call physician. This allows patients to be seen and evaluated by the physician during office hours for all their medication refills. I have read and understood the office policies as stated as above and my signature certifies my agreement to such policies.Patient or Guardian Signature*Today's Date: 05/17/2025CommentsThis field is for validation purposes and should be left unchanged.