BRADENTON WOMEN’S CENTER PATIENT REGISTRATION Surichya Surattanont MD FACOG
Name______Referred by______
Address______
City______State______Zip______
Social Security______Date of Birth______Age______
Home Phone______Cell Phone______
Work Phone______Extension ______
*Specifiy which number you prefer us to call first
Spouse’s/Partner’s Name______Home/Cell Phone______
Friend or Relative Not Living With You (Name)______
Address______
City & State______Zip______Phone______
PATIENT’S SIGNATURE ______(Please Sign Here)
PAGE 1 BRADENTON WOMEN’S CENTER ANNUAL UPDATE Surichya Surattanont MD FACOG
Name______Date______
DO YOU PRESENTLY HAVE… General Eye/Ear/Nose/Throat Cardiovascular □Fever/Chills □Vision changes □Chest pain □Weight changes □Difficulty swallowing □Arm or Neck pain □Fatigue □Neck Mass □Palpitations □Hearing Loss □Varicose veins □Sinus pain/infection □Leg Swelling Bone/Muscle/Joints □Paralysis Gastrointestinal Pulmonary □Numbness □Constipation □Short of Breath □Joint swelling □Diarrhea □Chronic cough □Joint pain □Rectal bleeding □Sputum □Stomach pain
Skin □Nausea/Vomit Urinary □Rashes □Poor appetite □Pain on urinating □Changes in moles □Urine leak □Changes in birthmarks □Frequent urination □Sores that do not heal
DO YOU PRESENTLY HAVE… □Irregular bleeding □Painful periods □Bleeding between periods □Vaginal discharge □Vaginal itching/irritation □Vulvar itching/irritation □Pelvic pain □Painful intercourse □Postmenopausal bleeding □Hot Flashes □PMS/Mood swings □Decrease sex drive □Feeling of something □Feeling of mass □Breast Mass/Pain □Breast Discharge falling out of vagina in vagina
DO YOU HAVE A HISTORY… □AIDS/HIV □Emphysema □Irr. Bowel Syndrome □Parkinson/Alzheimer □Tonsillitis □Alcoholism □Epilepsy □Hypertension/High Blood Press □PID □Tuberculosis □Anemia □Genital Wart□Kidney/Bladder □Pneumonia □Ulcer/Colitis □Arthritis □Glaucoma □Liver Disease □Psychiatric □Sexual Abuse □Asthma □Gout □Lung Disease □Skin Problems
□Bronchitis □Heart Attack□Lupus □Stomach/Bowel □Cancer □Heart Problem □Migraines □Stroke □Chlamydia □Hepatitis □Mitral Valve □Syphilis □Diabetes/ □Herpes □Multiple Sclerosis □Thyroid Problem Sugar prob
DO YOU HAVE A HISTORY OF… MEDICATIONS: □Abnormal mammogram □ Cone Biopsy/LEEP 1.______□Abnormal PAP □Endometriosis □Adenomyosis □ Fibroid Uterus 2.______□Bartholin Cyst □Lichen Sclerosis □Breast Disease □Ovary Cyst/Mass 3.______□ Colposcopy □Vestibulitis 4.______Allergies:______PAGE 2 BRADENTON WOMEN’S CENTER Surichya Surattanont MD FACOG
Name______Soc Sec______Date______
LIST ALL PREGNANCIES
Vaginal Length of Place of Year C-Section Labor/ Wt of baby Delivery Complications
LIST ALL SURGERIES
Year Type of Surgery Physician Hospital/City 3 LIST ALL HOSPITAL STAYS THAT ARE NOT SURGERY
Year Illness Treatment/Medication Physician
Current Age or Age at Death Major Illnesses Cause of Death Surgeries Mother Father Grandmother Grandfather Brothers Sisters PAGE 3 BRADENTON WOMEN’S CENTER Surichya Surattanont MD FACOG
Patient Consent for Receipt and Transmittal of Protected Health Information
DO WE HAVE PERMISSION TO:
1. Mail notices to your home address YES______NO______
2. Leave the following information on you HOME answering machine/voice mail :
Appointment Information YES______NO______
Billing Information YES______NO______
Medical Information YES______NO______
3. Leave the following information on your WORK answering machine/voice mail :
Appointment Information YES______NO______
Billing Information YES______NO______
Medical Information YES______NO______4. I give permission to share APPOINTMENT information and BILLING information with the person listed below :
Name:______
5. I give permission to share MEDICAL information with the person listed below:
Name:______
Patient Name______
Patient Signature______
Guardian Signature______(If under 18 years old)
PAGE 4 AGREEMENT FOR PROFESSIONAL SERVICES
I understand that by signing below I am consenting to receive professional services from Bradenton Women’s Center PA, Surichya Surattanont MD, and the clinical staff. This may include but is not limited to medical services, medical testing, labs, counseling, and any other intervention deemed necessary for your well being. I understand that no guarantee or assurance has been made as to the results that may be obtained from the services rendered.
I understand the Bradenton Women’s Center PA will bill me for all services thereafter which may include but are not limited to medical services, medical testing, lab services, cousultations, school physicals, blood draws, FMLA forms, filling out Employer or government required forms, record reviews, counseling, and other medical and alternative health interventions deemed necessary for your well being. I also understand that I am responsible for paying out of pocket expenses incurred such as photocopy cost of requested medical records. I agree to assign to Bradenton Women’s Center PA any and all third party benefits to which I may be entitled as a result of the services rendered to me pursuant to this agreement, including but not limited to Medicare, health insurance or settlement proceeds and I hereby authorize payment to be made directly to Bradenton Women’s Center PA.
I understand that different insurance policies have different coverage and I agree that I am ultimately obligated to pay for all services rendered on the day they are rendered regardless of whether it is a covered benefit or not under my insurance policy. I will pay any applicable copay, coinsurance and deductible for any services rendered at the time that service is rendered. I authorize the release of protected health information to the extent necessary to process claims for benefits.
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AGREEMENT FOR PROFESSIONAL SERVICES PAGE 2
In the case treatment is being provided to a minor, I consent for ______to any diagnostic procedures including the fully physical and gynecological exam and all medical, lab, and other services outlined above that may be deemed necessary to the well being of the minor under my care/guardianship.
In the event Surichya Surattanont MD or her clinical staff is called to testify in any legal proceedings concerning the services provided under this agreement, I will pay for all time incurred, even if called by another party. I also agree that I will not file suit against Bradenton Women’s Center PA / Surichya Surattanont MD in any court located outside of Manatee County Florida unless no courts with jurisdiction exist in that county. I further consent to venue in said county for all actions that may be brought against me arising out of this agreement and agree not to seek the transfer of any action to another county. I understand that protected health information may be disclosed to the extent necessary for Bradenton Women’s Center to enforce her rights under this agreement. I further acknowledge that I may terminate treatment at any time. I also acknowledge that Bradenton Women’s Center PA, Surichya Surattanont MD or her clinical staff may terminate treatment at any time for any reason whatsoever.
My signature below indicates that I have read this agreement and agree to its terms and also serves as an acknowledgement that I have received notice of my HIPPA rights.
______
Patient Date
______Minor if applicable
PAGE 6 PAYMENT CONSENT FORM
Patient Name ______
Last First
Name on Card ______
Last First
I authorize Bradenton Women’s Center PA , Surichya Surattanont MD, (the “provider”) to charge my card for professional services as follows:
To charge my card for all charges incurred by me with Provider. I understand that Provider may seek payment from my insurance company prior to charging my card. However I am ultimately responsible for all charges incurred and authorize payment from this card for any amounts not actually received by Provider I may revoke this authorization at any time, except that Provider may charge my card for any charges incurred prior to receipt of my notice of revocation and may decline to provide further services until a substitute card is authorize. If I have questions about any charges, I agree to contact Provider. I agree that I will not pursue a refund directly through my credit/debit card company, bank or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee incurred by my provider.
Type of Card Visa Mastercard Discover
Card Number ______- ______- ______Exp Date______
Security Code ______
Card Holder Billing Address______
______
Card Holder Signature ______Date
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