Online waiver | Waiver app - The World's Leading Digital Waiver Application

Date:*(MM/DD/YYYY)

Name:*

MI:*

Date Birth:*(MM/DD/YYYY)

Age:*

Address: *

Same as above

Cell Phone:*

Email: *

Please Circle:*

Male

Female

Marital Status:*

How Long:*

Pharmacy:*

Phone:*

In case of Emergency who to contact:

Name:*

Phone:*

Please list Primary Physician(s) contact information:

Physician/Facility:*

Phone:*

Please list medical concerns in order of importance (chief complaint #1):*

Operations: Please include year of operation

Appendectomy*

Tonsillectomy*

Prostate*

Hysterectomy (partial or total)*

Cholecystectomy*

Other*

Preventative Care:

Annual Physical:*

No

Yes

Mammogram:*

No

Yes

Colonoscopy:*

No

Yes

Labs:*

No

Yes

Pap Smear:*

No

Yes

Last Menstrual Period:*

Bone Density Scan:*

No

Yes

Prostate Exam:*

No

Yes

Other:*

Allergies (please list): Please include reaction*

Please list contact information for any physician(s) or facilities that have treated you for the condition that you are seeking treatment for (if applicable) …

Physician/Facility:*

Phone:*

Physician/Facility:*

Phone:*

Please list any prescription medications, OTCs (over the counter medications), vitamins, minerals, supplements you are taking. Please list the amounts (i.e., 500 mg tablet two times/day), when you take them (schedule) and why you are taking them. If you need more room, you can attach a list or use the back of this page.*

Physical History: Please check all if you have or had any of the systems.

Physical History: Please check all that apply

Social History: Please circle all that apply.

Children:*

No

Yes

Cigarettes:*

No

Yes

Cigars:*

No

Yes

Alcohol:*

No

Yes

Coffee:*

No

Yes

Chewing Tobacco:*

Yes

No

PMI/FH:

Have you or any of your family members had any of the problems listed in this chart? Please indicate by checking the appropriate box.

READ THOROUGHLY BEFORE SIGNING

PATIENT ACKNOWLEDGEMENT OF

RECEIPT OF PRIVACY NOTICE

I hereby acknowledge receipt of the Notice of Privacy Practices for Florida Renu Hormones and Wellness regarding my health information. I have been informed and understand the way my health information shall be maintained, utilized, and disclosed by Clinic and my respective rights contained therein. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time by contacting FLORIDA RENU HORMONES AND WELLNESS, 2632 Hollywood Blvd, #208, Hollywood, FL 33020.

ACKNOWLEGEMENT OF FEES

I hereby acknowledge receipt of notice that Florida Renu Hormones and Wellness does NOT file health insurance claims currently. I understand that I am personally responsible for payment in full for the care that I receive at the time of service. Once a service has been rendered the fees paid are non-refundable. Florida Renu Hormones and Wellness will provide you with documentation to submit to your insurance carrier so that you may be reimbursed for your medical expenses directly. I further understand and agree that if Florida Renu Hormones and Wellness must take any action to collect an outstanding balance on my account, I will be responsible for payment of and will reimburse this office for all costs of such collection efforts, including but not limited to staff expenses at a rate of $25 per hour, court costs, postage, and attorney fees. I agree with the provided services fee schedule.

OFFICE WAITING AREA POLICY

Florida Renu Hormones and Wellness, Inc. is a small medical office with extremely limited space for guests waiting. We must ask our patients to limit the number of guests with them to one guest. We apologize for the inconvenience and appreciate your understanding. Additionally, there is no food or drinks other than water permitted in the waiting area. By signing this, you are agreeing to honor these office policies.

CONSENT TO TREAT

I hereby authorize the Doctor and/or APRN to treat my case as they deem appropriate.

Patient Signature:*

Click to sign

Date:*(MM/DD/YYYY)

NOTE: Your health information will be kept strictly confidential. Any information that we collect about you on this form will be kept confidential in our offices.

PERMISSION TO RELEASE MEDICAL RECORDS

I, name listed as below, request the release of my medical records:

Please indicate what information you would like released:

ANY AND ALL TREATMENT AND DIAGNOSTIC RECORDS

Said records are to be sent to:

Florida Renu Hormones and Wellness

2632 Hollywood Blvd., # 208

Hollywood, FL 33020

Office: 954-842-2231

I recognize the material requested is part of my permanent medical record and now hold harmless*

from all claims resulting from this release.

Patient Signature*

Click to sign

Name:*

Date:*(MM/DD/YYYY)

Date of Birth: *(MM/DD/YYYY)

Witness Signature*

Click to sign

Date:*(MM/DD/YYYY)

FR BHRT Patient Intake Form