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The Physician's Group S.C. Patient Intake Form

Patient Information

Today's Date * +

Your Birth Date * 🛈 +

Gender *

Male

Female

First Name

Last Name *

Street Address

Address Line 2

City

State

Zip Code

Cell Phone Number *

Email Address *

Height *

Weight *

Employment Information

Place of Employment

Primary Guaruntor's Employer

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

IF THE PATIENT IS A MINOR, please have the parent(s)/guardian(s) complete this section to authorize treatment.

Primary Guarantor/Parent/Guardian Name:

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Home Phone Number

Cell Phone Number

Work Phone Number

Email Address

Secondary Guarantor/Parent/Guardian Name:

First Name

Last Name

Social Security Number

Street Address

Address Line 2

City

State

Zip Code

Home Phone Number

Cell Phone Number

Work Phone Number

Email Address

Appointment Information

Reason of Visit *

Work Related Injury

Routine Consultation

Emergency Room Patient

Cosmetic

Please specify reason of visit. *

If you are here due to a work related injury, please fill out the information below:

Employer's Name

Billing Company Name

Billing Company Address Line 1

Address Line 2

City

State

Zip Code

Billing Company Phone Number

Billing Company Fax Number

Billing Company Email

Past Medical History

Do any of the following apply to you? Please include past and present conditions. If not, please select "None." *

Please list all other conditions here, separated by a comma.

Allergies and Medications

Do you have any known allergies? *

No

Yes

Please list any allergies, separated by a comma.

Are you on any of the following medications? If not please select "None" *

Please list all other medications here, separated by a comma.

Contact by Email

*

I would like to receive emails on rebates

I would like to receive emails on promotions

I would not like to receive emails

Agreement

Please initial after you have read the paragraph above. *

PLEASE UPLOAD A PICTURE OF YOUR DRIVER'S LICENSE OR STATE ISSUED IDENTIFICATION CARD

PLEASE UPLOAD THE BACK OF YOUR INSURANCE CARD

PLEASE UPLOAD THE FRONT OF YOUR INSURANCE CARD

Save & Return Account (optional)

New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish. The account you establish is only for this form.

PLEASE PROVIDE VALID PICTURE I.D. & PRIVATE INSURANCE CARD.

YOU WILL BE GIVEN THE OPPORTUNITY TO UPLOAD A PICTURE OF YOUR INSURANCE CARD (FRONT AND BACK) AND YOUR DRIVER'S LICENSE.

CONSENT TO HEALTH CARE SERVICES

I, the undersigned Patient, or undersigned person responsible for consenting on patient’s behalf hereby request and consent to The Physicians Group S.C. to be examined and treated by the medical, nursing and other healthcare personnel who may participate in the Patient’s care.

I hereby acknowledge that all information provided herein is true to the best of my knowledge. I hereby assign, transfer and set over to The Physicians Group S.C. all of my rights, title 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 I revoke said authorization and give written notice. I understand that my co-pay, if applicable, is due prior to being seen and if my co-pay is not paid I might have to reschedule my appointment.

I hereby agree to provide complete and accurate information to the best of my ability about my health, any medication taken, including over-the-counter products and dietary supplements, and any allergies or sensitivities.

Upon becoming a patient of The Physician's Group S.C. I hereby agree to follow the agreed-upon treatment plan prescribed by The Physician's Group S.C. and participate in their care.

I hereby agree to provide a responsible adult for transportation home and to remain with me as directed by the provider or as indicated on discharge instructions.

I understand that all cancelations of appointments must be made 24 hours in advance and rescheduled within the same business week whenever possible. I understand that there will be $10.00 charge for all appointments canceled with less than 24 hour notice, unless the appointment is rescheduled.

I understand that there will be a $25.00 charge for all appointments missed with no call made canceling the appointment. I also understand that three consecutive no show appointments may result in discharge from The Physicians Group S.C.

I hereby agree to pay the regular charges of the physician for any treatment performed on my behalf or authorized by me.

I understand that I am financially responsible for all charges whether or not they are covered by my insurance plan or fall into the insurance company’s definition of usual and customary. The Physicians Group S.C. is committed to providing the best treatment possible for our patients and our charges are considered usual and customary for our area.

I understand that all bills are to be paid in full within 45 days of submission to my insurance company. The Physicians Group S.C. does not wait for the settlement of lawsuits. Interest of 1 ½ % per month up to 9% annually will be charged after 60 days. An authorized, approved payment plan will eliminate interest charges and collections.

I understand that I am responsible for all costs of collections for any outstanding fees, including but not limited to any attorney fees, court costs, expenses and interest incurred from the dare of my initial consultation with any physician at The Physicians Group S.C.

I hereby agree to behave respectfully toward all health care professionals and staff, as well as other patients and visitors at The Physician's Group S.C.