Patient Forms — Sharif Surgical, P.L.L.C.

Section 1 — Patient & Insurance Information

Referring Physicians & Pharmacy

Referring Doctor & Phone No.

Preferred Pharmacy

Primary Care Doctor & Phone No.

Pharmacy Phone #

Pain Management Doctor

Cardiologist

Oncologist

Gastroenterologist

Patient Information (Please Print)

Title

Mr. Mrs. Ms.

Last Name *

First Name *

MI

Date of Birth *

Sex

Male Female

Address *

City *

State

Zip Code

Home Phone

Cell *

Work Phone

Race / Ethnicity

Email Address *

Marital Status

Single Married Widowed Divorced

SSN

Employer

Occupation

Insurance Information — Please give your insurance card to the receptionist

Primary Insurance

Primary Insurance Co.

Effective Date

Name of Policy Holder

Relationship to Patient

Policy Holder Date of Birth

Secondary Insurance

Secondary Insurance Co.

Effective Date

Name of Policy Holder

Relationship to Patient

Policy Holder Date of Birth

Responsible Party Information (If Different Than Above)

Last Name

First Name

MI

Address

City

State

Zip

Home Phone

Cell

Work

SSN

Date of Birth

Sex

Male Female

Employer

Occupation

Relationship to Patient

Section 2 — Patient History & Physical Form

Patient Details

Today's Date

Patient Name

Date of Birth

Surgical History

Type of Surgery	Year	Additional Surgery

Family History of Cancer

Family Member	Type of Cancer	Date Diagnosed	Living or Deceased

Cancer Screenings

Last Pap

Last Colonoscopy

Last Stress Test

Current Medications

Medication NameDosageFrequency

Medication Allergies

List all medication allergies and reactions

Social History

Section 3 — Consent to Treatment & Assignment of Benefits

Consent to Treatment & Assignment of Benefits

Signature of Patient or Representative

Patient Signature *

Sign above using mouse or touch

Date *

Assignment of Benefits — Patient Intake

Patient Signature *

Sign above using mouse or touch

Date

HIPAA Acknowledgment: I acknowledge that I have received a copy of the HIPAA Privacy Policies and understand that if I have any questions or complaints, I should contact the Privacy Official.

Patient Initials *

Consent to Obtain Medication History

About Your Medication History Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions. It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription health insurance available, and your medication history might not include drugs purchased without using your health insurance. Over-the-counter drugs, supplements, or herbal remedies that you take on your own may not be included in this history.

By signing this document, I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and any other healthcare providers.

Signature of Patient or Representative *

Sign above using mouse or touch

Date

Section 4 — Release of Medical Information to Family

Release of Medical Information to Family

In the event our office would need to release medical information on your behalf to someone in your family, if the family member is not listed on this form we cannot release your medical information. Please list someone in your family, or a friend that you would want to have your medical information in the event of an emergency.

Name	Phone Number (Home/Cell/Work)	Relationship

Important Note Please specify if the phone number is HM (Home), CELL, or WK (Work). Please do not include doctors. Thank you.

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