Adirondack Neurology Associates, PC / PATIENT REGISTRATION
454 Glen Street / (PLEASE PRINT)
Glens Falls, NY 12801
Phone (518) 793-9155 Fax: (518) 793-6778

PATIENT INFORMATION

Name: / Are You? [ ]Employed [ ]Retired [ ]Other
Address: / Employer:
Address:
City, St / City, State, Zip
Phone # / Phone:
Work # / Occupation:
Other # / Referring Physician:
Date of Birth: / Sex: / Primary Care Physician:
Social Security # / EMERGENCY CONTACT (Name, Phone Number)
Marital Status:

GUARANTOR (Person Responsible for Your Account After Insurance Has Paid)

[ ] Check here if Patient is Responsible for Bill

Name: / Employer:
Address: / Address:
City, State, Zip
City, St, Zip / Phone:
Phone #
Date of Birth: / Social Security #

PRIMARY INSURANCE

Insurance Name:

/ /

Insured ID#:

/ /

Group #:

/

[ ] Check here if Patient is also the Policyholder for this Insurance Plan

(If the patient is not the policyholder for this insurance plan, please provide the following information.)
Policyholder: / Phone:
Address: / Relationship to
City, St, Zip / Date of Birth

IF YOU WERE INJURED AT WORK OR INVOLVED IN AN AUTO ACCIDENT…

Were you Injured on the Job? / ___ Yes / Date of Injury / Insurance Company
Was an Automobile Involved? / ___ Yes / Date of Accident / Insurance Company
Adirondack Neurology Associates, PC PATIENT REGISTRATION
454 Glen Street / (PLEASE PRINT)
Glens Falls, NY 12801
Phone: (518) 793-9155

PLEASE TAKE A MOMENT TO ANSWER THE FOLLOWING QUESTIONS:

1.) Have you had any fevers or weight changes recently? YES NO

2.) Have you had any loss of vision in one eye or double vision? YES NO

3.) Have you had any hearing loss? YES NO

4.) Do you have a history of chest pain? YES NO

5.) Do you get short of breath easily? YES NO

6.) Do you have trouble with nausea and/ or vomiting? YES NO

7.) Do you have trouble with bowel and/ or bladder control? YES NO

8.) Do you have trouble with joint pain? YES NO

9.) Have you had any rashes recently? YES NO

10.) Do you have a history of anemia or are you on blood thinners? YES NO

PLEASE PROVIDE A BRIEF EXPLANATION OF ANY “YES” ANSWERS BELOW: ______

______

SOCIAL HISTORY: SMOKER ______PACKS PER DAY ______

ALCOHOL ______DRINKS PER DAY/WEEK ______

DO YOU HAVE A HISTORY PAST OR PRESENT OF ANY OF THESE DISEASES:

_____HIGH-BLOOD PRESSURE _____HEART _____SEIZURE

_____DIABETES _____ASTHMA _____ARTHRITIS

_____NEUROPATHY _____STROKE _____CANCER

_____MIGRAINE _____ULCER _____OTHER ______

DOES ANYONE IN YOUR IMMEDIATE FAMILY HAVE A HISTORY OF ANY OF THESE DISEASES:

_____HIGH-BLOOD PRESURE _____HEART _____SEIZURE

_____DIABETES _____ASTHMA _____ARTHRITIS

_____NEUROPATHY _____STROKE _____CANCER

_____MIGRAINE _____ULCER _____OTHER ______

YOUR CURRENT MEDICATIONS:

NAME DOSE HOW OFTEN REASON

______

ARE YOU ALLERGIC TO ANY MEDICATIONS: YES / NO , IF YES PLEASE LIST:

______

INSURANCE AUTHORIZATION AND ASSIGNMENT (Please read and sign)

I hereby authorize direct payment to Monica A. Burke, DO, Vinodrai M. Parmar, MD and/or Michael W. Lenihan, MD for medical benefits otherwise payable to me under terms of my insurance.
I authorize the release of any information necessary to process all future claims
I understand that I am financially responsible for all charges. If I do not promptly pay my bill, I agree to pay all costs of collection of the account including attorney fees. I also understand that I would be responsible for any and all expenses incurred in the event that I write a check that is returned for insufficient funds.
Authorized Signature of Parent/Guardian/Subscriber Date