Consent For Care And Treatment Form Page 3
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2
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4Practice:
Today’s Date:
Name:
______________________________________Chart #: _________ Date of birth: ____________
Race:
__________________________________________
I prefer not to answer
I do not know
(White, American Indian, Asian, Black or African, Native Hawaiian, Hispanic, etc.)
Ethnicity: __________________________________________
I prefer not to answer
I do not know
Preferred Language: _________________________________
I prefer not to answer
Pharmacy Name:
_________________________________
Pharmacy Phone: ____________________
Pharmacy Address:
_________________________________
City, State, Zip:
________________________
Primary Care Physician: _______________________ Phone: ______________ Date Last Seen: _____________
Address: ___________________________________________________________________________________
Referring Physician: ___________________________ Phone: _____________ Date Last Seen: _____________
Address: ___________________________________________________________________________________
Privacy Information Preferences
Do you want to be exempt from public reporting?
Yes
No
Can we send mail to the address on file?
Yes
No
Can we call the phone number on file?
Yes
No
Can we leave voicemail on machine?
Yes
No
Will you allow us to send internet based (e-mail) delivery of reminders and newsletters?
Yes
No
If yes, please provide your e-mail address: _________________________________________________________
Who can we leave messages with?
Wife
Husband
Daughter
Son
Other: ______________________
Name(s):______________________________________________________
Smoking Status
Vital Signs
Current Every Day Smoker
Never Smoker
Blood Pressure: _______ / ________
Current Some Day Smoker
I decline to answer
Height: ____________ Weight: ___________
Former Smoker
Current Medications
Allergies
No Known Allergies
No Known Medications
Reaction
No Known Drug Allergies
I take the following prescriptions/over the counter medications:
Penicillin
_______________________
Name: ______________________________ Dose _____
Shellfish
_______________________
Name: ______________________________ Dose _____
Sulfa
_______________________
Name: ______________________________ Dose _____
Tape
_______________________
Name: ______________________________ Dose _____
Latex
_______________________
Name: ______________________________ Dose _____
Betadine (iodine)
_______________________
Aspirin
_______________________
Name: ______________________________ Dose _____
Tylenol™
_______________________
Name: ______________________________ Dose _____
Ibuprofen
_______________________
Name: ______________________________ Dose _____
Codeine
_______________________
Use the back of this form if more room is needed
Other (specify)______________________________
PLEASE READ AND SIGN: The information on my intake form(s) is correct to the best of my knowledge. I understand that
throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information
listed above. (Assignment of Benefits): I authorize payment of medical benefits to the practice named above. (Release of Information):
I authorize the release of any medical information necessary to process this claim. (HIPAA Privacy): I acknowledge that I received
my HIPAA Privacy Practices Notice. (Medication History): I authorize the Doctor’s office to retrieve my medication history.
Patient Signature: _______________________________________
Date: ________________________
Rev 10/7/2011
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