Foris Surgical Group, L.L.P.

New Patient Medical HistoryPatient Name______________________________ Today’s Date_______________________________

Date of Birth________________________ Age__________ Sex__________

Who referred you to come see us today? ____________________________________________________________

Who is Your Usual Doctor/Nurse Practitioner/Physician’s Assistant?_______________________________________

Doctors you see regularly: ________________________________________________________________________

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OFFICE USE ONLY

Social History:

Occupation: ____________________________________________________________________________

Spouse/Significant Other’s Occupation: ______________________________________________________

Marital Status: Single Married Separated Divorced Widowed Declined to Answer

Tobacco: Never Smoked Former Smoker Currently Smoke ______ Packs per Day

Started Smoking at age_________ Quit Smoking at age_________

Do you use e-cigarettes/vape? No Yes

Alcohol Use: Never Yes ____ drinks/beers/glasses of wine (circle one) per day/week/month (circle one)

I am an alcoholic: No Yes I am a recovering alcoholic: No Yes

History of Drug Use: No Yes Type_______________

Caffeine Use: No Yes ______ cups per day (Coffee, Tea, Colas)

Hobbies: ________________________________________________________________________________

Past Surgical History:

Previous problems with anesthesia? Y___/N___

Describe Anesthesia Problem____________________________________________________________

Operation Year Operation Year

Allergies: (circle all that apply) Latex Iodine / Betadine Novocaine / Lidocaine Tape

Medicine Allergies (Drug name and Reaction)_______________________________________________

______________________________________________________________________________________________

Other Allergies:________________________________________________________________________________

Continued on Back

Patient Name______________________________________________ Date of Birth ________________

Current Medications (Please list all prescribed and over the counter medicines, vitamins and herbs):

Name Dose How often

DAILY ASPIRIN? Yes _____ No _____ BIRTH CONTROL PILLS? Yes _____ No_____

Your Personal Past Medical History Your Family’s Medical History

**Parents, Children & Siblings Only**

Past Medical Problem Yes No Description Yes No Description (family member)

High Blood Pressure

Heart Problems

Lung Problems

Liver Problems

Intestinal Problems

Kidney Problems

Strokes/TIA’s

Cancer(Please list type)

Diabetes

Bleeding Problems

History of Blood Clots

Other Significant Medical Problems ________________________________________________________________

______________________________________________________________________________________________

Please circle any illness or problems that you may have had within the last 30 days:

General None Fever , Chills, Night Sweats, Fatigue, Weight Gain, Weight Loss, Poor Appetite

Eyes None Blindness, Change in Vision, Inflammation, Poor Vision

Ear/Nose None Hearing Loss, Ringing in Ears, Nosebleeds, Hoarseness, Bleeding Gums

Respiratory None Cough, Wheeze, Shortness of Breath, Coughing up Blood

Cardiovascular None Abnormal EKG, Chest pain, Shortness of Breath, Irregular Heartbeat

Stomach None Abdominal Pain, Nausea, Vomiting, Blood in Stool, Black Stools, Heartburn,

Diarrhea, Constipation

Urinary None Blood in Urine, Frequency, Prostate or Testicular Problem, Heavy Menstruation

Muscle None Back Pain, Broken Bones, Disc Problems, Arthritis, Swollen Joints

Skin None Rash, Itching, Tattoos, Skin Infections, Recurrent Boils

Neurologic None Headaches, Seizures, Chronic Numbness, Dizziness, Weakness in Arms/Legs

Psychiatric None Depression, Anxiety, Abnormal Sleep

Hematologic None Easy Bruising, Blood Clots, Transfusions

Endocrine None Goiter, Thyroid Problems, Diabetes

Other Details:_______________________________________________________________

Foris Surgical Group, L.L.P.

45 Thomas Johnson Drive, Suite 211

Frederick, MD 21702

ADULT PATIENT REGISTRATION FORM

Full Name (Last, First, Middle): __________________________________________ Nickname: _________________

Street/Mailing Address: _____________________________________________________________________________

City: _________________________________ State: _________________Zip: ________________________________

Phone Numbers: (Home) ____________________ (Mobile) ____________________ (Work) ____________________

Date of Birth: _____________________ Social Security #:___________________________

Gender: � Male � Female

Marital Status:� Single � Married � Widowed � Divorced � Separated

Race: � American Indian � Asian � Black � Native Hawaiian � White � Declined

Ethnicity: � Hispanic Origin � Non-Hispanic Origin � Declined

Preferred Language: � English � Spanish � American Sign Language � Other ________________________

Consent to communication via patient portal - Email: ___________________________________________________

Employer: _________________________________ Address: ______________________________________________

Phone: _____________________ Occupation: ___________________________________________________________

(If retired – give previous employer and date retired)

Are you: Student? � Disabled? � Explain: ____________________________________________________

Primary Care Doctor: __________________________ Other Involved Providers: _____________________________

Whom may we thank for referring you to us? __________________________________________________________

Spouse (Name): ___________________________ Date of Birth:___________ Social Security#: __________________

Gender: � Male � Female

Mobile Phone: ____________________ Work Phone: ____________________ Occupation: _____________________

Employer: ______________________________Employer Address: _________________________________________

(If retired – give previous employer and date retired)

For Emergency Contact:

Name of a Friend or Relative Not in the Same Household: ______________________Relationship:_______________

Phone Numbers: (Home) ___________________ (Mobile) _____________________ (Work) ____________________

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Foris Surgical Group, L.L.P.

Patient Name:______________________________________ Date of Birth:___________________________

Accident Information:

I am here as a result of a � Work Injury � Auto Accident � Other Accident � Not Applicable

It Occurred:

Date & Time: ________________________________ Place: _______________________________________________

Describe how accident occurred: _____________________________________________________________________

Person to Contact: ______________________________________________ Phone Number: _____________________

Insurance Information – (Please allow us to attach a copy of your Insurance Card(s) and Photo ID)

1) Primary Insurance Company______________________________________________________________________

Member Name_______________________ Date of Birth_____________ SSN__________________________

2) Secondary Insurance Company_____________________________________________________________________

Member Name_______________________ Date of Birth_____________ SSN__________________________

I am responsible for all charges incurred, but I authorize Drs. Brand and Artusio to apply for benefits on my

behalf for services rendered. I authorize the release of medical information necessary to the claim. I request that

payment be made directly to Foris Surgical Group, LLP. I permit a copy of this authorization to be used in place

of original. Should my account be sent to a collection agency, I agree to be financially responsible for all collection

fees and legal fees that Foris Surgical Group, LLP incurs through the process utilized to collect the outstanding

delinquent balance.

I authorize release of medical information to my requesting/referring and/or family doctor and other providers

and facilities involved in my care. I authorize Foris Surgical Group, LLP representatives to access my Frederick

Memorial Hospital records.

I agree that Foris Surgical Group, LLP may request and use my prescription medication history from other

healthcare providers or third-party pharmacy benefit payors for treatment purposes.

I authorize Foris Surgical Group, LLP to send Appointment Reminders electronically via Text Message to my

mobile phone. I understand this is offered free of charge; however, standard text messaging rates from my mobile

carrier may apply. I agree not to hold Foris Surgical Group, LLP liable for any electronic messaging charges or

fees generated by this service. I also understand that I may revoke this permission in writing at any time. Please

activate text message reminders for the following patient and mobile phone number:

__________________________ __________________________ _________________________________ Patient Name Mobile # Mobile Carrier

Signature _________________________________________________________ Date __________________________

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As a convenience to you for future need, we are providing this opportunity in advance for you to designate any person to whom you may wish us to provide otherwise confidential medical information

from your records (for example: biopsy results, blood test or x-ray results).

(For example, this may be a spouse, “significant other”, caregiver, close friend, adult child, etc.)(For patients under 18 years of age, please list all parents, step parents, guardians, caregivers as needed)

AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION

TO: FORIS SURGICAL GROUP, LLP

CONCERNING THE MEDICAL RECORDS OF:______________________________ Patient Name

Patient’s Date of Birth:__________________ Patient’s SSN:___________________

I, the undersigned, hereby authorize and request Foris Surgical Group, LLP, to provide the following persons:

Full Name Relationship to Patient Date of Birth or Maiden Name

_________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

with any information they request from my medical records or from my surgeon or other representatives of Foris Surgical Group, LLP. This may include copies of written reports or verbal communication by phone or in-person. This authorization is valid for any and all information related to medical histories, problems, diagnoses, tests, and treatments of the above identified patient.

I understand that the medical information to be released may contain information related to HIV status, AIDS, hepatitis, sexually-transmitted disease, pregnancy, alcohol or drug use, or mental health services, and I hereby authorize the release of this information.

This authorization for disclosure is valid for a period of one (1) year and may be withdrawn by me at any time, except during an action taken in response thereon.

____________________________________________________________________________________Signature of “Person of Interest” (If signer is other than patient, please print name, too.)

(“Person of Interest” may be 1) an adult patient, 2) a person authorized to consent to health care for the patient, 3) a minor if the record concerns treatment to which a minor has the right to consent, 4) parent of a minor unless limited by a court order or a valid separation agreement, 5) a legal guardian; custodian or representative designated by a court.)

Date Signed____________________ Signature witnessed by________________________________Foris Surgical Group, LLP staff member

Financial Policy for Foris Surgical Group LLP

We are dedicated to providing you with the best possible care and service, and regard yourunderstanding of our financial policies as an essential element of your care and treatment. To assist you,we have the following policies. If you have any questions, please feel free to discuss them with our staffprior to signing this document.

Basic Policy: Unless other arrangements have been made in advance by either yourself or your healthcoverage carrier, full payment is due at the time of service. Your insurance coverage is a contractbetween you and your insurance company. We will be happy to file a claim on your behalf; however, anyco-payment, co-insurance, or deductible is due at the time of service. In the event your insurance carrierdetermines a service to be “not covered” you will be responsible for the entire fee. For your convenience,we accept cash, checks, Discover, MasterCard and Visa.

Surgery Policy: If it is determined that you will need surgery, our staff will contact your insurancecompany to verify benefits and determine the estimated amount that you will be responsible for. Yourinsurance co-payment, co-insurance, and/or deductible will be due at the time of scheduling. If it isnecessary to make partial payment, the remainder must be paid before surgery unless otherarrangements are made in advance.

HMO Patients: It is your responsibility to know and obtain a referral from your Primary Care Physician ifyour insurance requires one. Our office staff will notify and assist you in referral/precertificationrequirements. All referrals must be presented to our business office before seeing the doctor. If there isno referral, you may be required to reschedule or will be asked to contact your physician to have it faxed.If you choose to see the surgeon without the needed referral, you will be required to sign a notice statingyou are responsible for the cost of the visit if a referral is not received. If you will not be bringing yourreferral with you, we recommend calling before your appointment to verify that we have received thereferral.

Missed Appointments: Please be on time for your appointment. If you need to reschedule yourappointment, we ask you to please give us 24 hours advanced notification. If you miss a scheduledappointment without notifying our office, a $100.00 charge may be added to your account.

Medical Records: Original office records are part of our medical records and cannot leave our office. Ifcopies are needed for your doctor, we will mail or fax them to that office. If you request a copy of yourmedical records for personal use, a per page fee will be charged and payment is required in advance forcopying the records. Please allow one week notice to copy medical records.

Returned Checks: There is a $25.00 charge for all returned checks. Please be advised that if yourcheck is returned to us for any reason, we will only accept cash or credit cards as payment.

Disability Forms/Dictated Letters: There is a $25.00 fee to be paid in advance for the completion ofdisability forms. A fee of $25.00 will be charged if a patient is requesting a dictated letter from thephysician. Please allow 3-5 business days for completion of all forms or letters.

________ Delinquent Accounts: We reserve the right to add collection and legal fees to any account over 30 daysInitial past due. The collection fee accessed to delinquent accounts is 33% of the outstanding balance due.

I have read and understand the financial policy of the practice and I agree to be bound by itsterms. I also understand and agree that such terms may be amended from time-to-time by thepractice.

______________________________________ _________________________Signature of Patient or Responsible Party if a Minor Date

______________________________________Please Print the Name of the Patient

5/10/2017