Date:_________________                                                                             Office Record:_______________

Name:__________________________________________________________________________________

                First                                                      MI                                          Last

SS#:______________________DOB:___________Age:____Race_____Sex_______Marital Status_______

Address:________________________________________________________________________________

                Street Address or PO Box                                       City                      State                      Zip

Home Telephone #____________________ Work #____________________ Cell #____________________

Your Employer:_______________________________________  Spouse’s Name:_____________________

Who is your Family Doctor?______________________Who referred you to us?_______________________

Emergency Contact Name:______________________________Telephone #:_________________________

IF A MINOR:

Responsible Party:________________________________________________________________________

                                    First                                      MI                                     Last

Address:________________________________________________________________________________

                  Street Address or PO Box                                     City                       State                      Zip

Home Telephone Number:___________________Work #:____________________Cell #:_______________

Employer:_______________________________________________________________________________

DO WE HAVE YOUR PERMISSION TO:

Leave a message on your home answering machine/voicemail?    Yes    No

Leave a message with a family member/member of your household?   Yes   No

Leave a message at your place of employment?   Yes   No

Discuss your medical condition with a family member/

member of your household/friend/other?     Yes   No      If yes, whom:_________________________________

Release any of your medical information (office notes, lab reports, etc…) to a family member/

member of your household/friend/other?     Yes   No  If yes, whom:___________________________________

Discuss your medical billing or insurance information with a family member/

INSURANCE INFORMATION: (Please present insurance card(s) at check in.):

Primary Insurance:_______________________________   Secondary Insurance:________________________

Policy Holder:___________________________________    Policy Holder:_____________________________

SS#:_________________________DOB:_____________    SS#:_____________________DOB:___________

EMPLOYMENT STATUS:  Full-time/Part-time/Retired/Self/Not employed/Active duty/Inactive duty

STUDENT STATUS:  Full-time/Part-time/Not a student

Is there a chance you could be pregnant?   Yes    No

Are you enrolled in a hospice program?     Yes    No

Have you recently had kidney x-rays?   Yes    No

Pharmacy you use:____________________________ Phone#__________________

I hereby assign, and set over to Eastern Urological Associates, P.A. all of my rights and interest to my medical reimbursement benefits under my insurance policy.  I authorize the release of any medical information needed to determine these benefits.  This authorization shall remain valid until written notice is given by me revoking said authorization.  I understand that I am financially responsible for all charges not covered/paid by my insurance company.  I hereby give my consent for Eastern Urological Associates, P.A. to use and disclose Protected Health Information about me, to carry out treatment, payment, and healthcare operations.

 ___________________________________________________                   Date:_________________________

    Patient or Guardian’s Signature

 I have received a copy of the Eastern Urological Notice of Privacy Practices.  I am aware that the notice may be changed at any time.  I may obtain a revised copy of the Notice by writing to the Privacy Officer at Eastern Urological Associates, P.A., or by requesting one at the Eastern Urological provider location.  ***You may pick one up at the front desk.

 ___________________________________________________                   Date:_________________________

     Patient or Guardian’s Signature