Adult Registration Form printable pdf download

REGISTRATION FORM

MUST BE COMPLETED USING A BLACK INK PEN

Patient’s Legal Name: ___________________________________________________ M/F: ______ Date of Birth: ___________________

Marital Status: __________ Cellular Phone/Other: __________________________ Home Phone: ______________________________

Address: ______________________________________________________________________________________________________________

Street

City

State

Zip

Employer: ____________________________ Work Phone: ___________________________

E-Mail: __________________________ would you like to receive updates about future programs via E-mail? Circle Yes No

I authorize Melmed Center to contact me by telephone with medical information pertaining to my care. If I am

unavailable, this authorization gives Melmed Center permission to leave this information either on my answering

machine or with a member of my household .

Authorized Individuals

The following people are authorized to discuss my personal health information and coordinate with the Melmed Center for

evaluation and treatment, including follow up appointments, telephone communication, scheduling appointments and may be

contacted in case of an emergency

(Authorized caregivers are not able to request and transfer records)

Name_________________________________________________ Relationship_____________Phone Number _______________

***PLEASE READ***CANCELLED/MISSED APPOINTMENTS***

A SCHEDULED APPOINTMENT MEANS THAT TIME IS RESERVED ONLY FOR YOU. IF AN APPOINMENT IS MISSED OR

CANCELLED FOR ANY REASON, WITH LESS THAN 48 HOURS NOTICE, THE PATIENT WILL BE BILLED ACCORDING TO

THE SCHEDULED FEE. THIS FEE IS NOT GENERALLY PAID BY AN INSURANCE COMPANY.

______________________ Date: _____________

Signature:

PRESCRIPTION REFILL POLICY

Our office policy is that all prescription refill requests must be made 7-10 working days in advance of running out of the

medication. Refills will only be approved if follow up visits have been kept every 2-3 months. Prescriptions will be

handled only during office hours. Initial: ________________________

The Melmed Center has therapy/service animals in our office. It is your responsibility to notify our office, prior to

your appointment, if you have fear of, or allergies to dogs. Melmed Center will not be held liable for any incidents such

as licking, nibbling, or physical contact from the dog(s). By signing this document you are aware we do have

service/therapy animals in our office. Please contact us if you have any further questions.

I UNDERSTAND AND AGREE TO ALL OF THE ABOVE_________________________________________ Date __________

Signature of Patient

Please turn the page over and complete the other side →

3/26/14 Adult Revision

Adult Registration Form