New Patient Registration Paperwork

The paperwork consists of 3 sections. You must complete all sections with a red *. If you click submit, and do not see a message confirming or “thanking” you for the submission, then please scroll up and review what section was not completed. Paperwork is not submitted unless you get the confirmation message. You will receive 1 for each section , so 3 total. Thank you! 

*Please note: There is a $50 cancellation policy if you do not notify us within 24 hours of your appointment if you need to cancel or reschedule*

Appointment Date *
Appointment Date
Please check one *
Appointment with *
Name *
Name
Please choose one *
Date of Birth *
Date of Birth
Address *
Address
Home Phone *
Home Phone
Cell Phone *
Cell Phone
Best number to confirm appointment during the day *
How did you hear about Fagan Sports Medicine? *
Insurance Information
Policy Holder's Name *
Policy Holder's Name
Policy Holder's Date of Birth *
Policy Holder's Date of Birth
Address of Policy Holder *
Address of Policy Holder
Name of Primary Care Physician (PCP) *
Name of Primary Care Physician (PCP)
Do you want today's office note sent to your PCP? *
When did your symptoms start? *
When did your symptoms start?
Chief Complaint: (If you have a new issue for which you are not scheduled for, please inform the Medical Assistant) *
Please select chief complaint -only one please *
Context *
Do you have radiating pain? *
Severity of Symptoms *
Frequency *
Status of Symptoms *
Aggravated by *
Relieved by *
Associated Symptoms *

Patient Medical History

SECTION 2: Medical History  (please make sure you click submit above and get a confirmation prior to moving forward with section2 below)

Name *
Name
Appointment Date *
Appointment Date
Check all that apply to your medical history *
Check all that apply to your immediate family (parents, siblings, grandparents) *
REVIEW OF SYMPTOMS: Check all symptoms you are currently experiencing *
Are you currently using or do you have a history of tobacco use? *
Please describe your alcohol consumption *
Please describe your exercise status *
If you are a woman, are you currently pregnant, or is there a possibility that you are pregnant? *
Hand Dominance *
Pharmacy Phone Number *
Pharmacy Phone Number

Authorization/HIPAA Form

SECTION 3: Authorization/HIPAA  (please make sure you click submit above and get a confirmation prior to moving forward with section3 below)

Name *
Name
Appointment Date *
Appointment Date
Authorization
Patient and/or Guarantor are responsible for charges incurred. It is a courtesy for our office to file your insurance; however, you are responsible for your co-pay and /or percentage, which the insurance company is not liable for , on the day of your visit. In the event your insurance company has not paid within 60days, you may be responsible for the balance due. It is also the patient's responsibility to obtain referrals for your primary care physician when required. If the referral is not obtained before the visit, the patient is liable for payment in full on the date of service. If we are unable to obtain payment within a reasonable amount of time of the patient and /or guarantor we will place your account with a collection agency which will leave you liable for additional expenses incurred if applicable. Fagan LLC , reserves the right to CHARGE for NO SHOW APPOINTMENTS, as well as appointments cancelled without 24hours advance notice. If notice is not given in time, or not at all, then the patient may be charged a fee of $35.00. We may draw labs here at our office should the need arise. If this option becomes available, there is a $10 lab draw fee for our office to be paid at time of service. This is a non-billable charge to insurance. Should you request consultation with either Physician via the phone; a phone consultation charge will be billed to you. The fee ranges from $15-$45 for the length of the call.
Please select below *
Signed by *
Signed by
Date *
Date
Note of Privacy Practices
Notice of Privacy Practices I acknowledge that I have received a written copy of the Fagan , LLC Notice of Privacy Practices. I also acknowledge that I have been allowed to ask questions concerning this notice and my rights under this notice. I understand that this form will be a part of my record until such time as I may choose to revoke acknowledgement. If I am not the patient, I represent that I am authorized by law to act for and on the patient’s behalf. Please list your PCP’s name if you would like for your notes to be sent to their office as well. In accordance with Fagan Sports Medicine’s notice of Privacy Practices, I herein request/authorize the release of my protected health information to the following people:
Signed by *
Signed by
Date *
Date