NILESH D. PATEL M.D., P.C.
Diplomate American Board of Otolaryngology
NEW PATIENT HISTORY FORM
PATIENT NAME:DOB:DATE:
REFERRING PHYSICIAN:
CHIEF COMPLAINT (What is the reason for your visit today?
HISTORY OF PRESENT ILLNESS
Location of problem:
EarsNose/sinusThroatMouthOther:______
When did you first notice the problem?
Today1 week agoAlways thereOther:______
Do you have pain?NoYes
If Yes, Please circle the level of pain (1 being least, 10 being most severe) 1 2 3 4 5 6 7 8 9 10
Any medications taken for relief of symptoms?NoYes
If Yes, What did you take?______Did it relieve you? No Yes
Please answer ALL of the following questions.
NILESH D. PATEL M.D., P.C.
Diplomate American Board of Otolaryngology
Date:______
Patient Name:______D.O.B______
Height:
Weight:
Please List All Of Your Current Medications.
______
What Medications Are You Allergic To?
______
______
Registration: PLEASE FILL OUT ENTIRE FORM Dr. Nilesh PatelLast Name: / First Name: / Gender
Birthdate: / Age: / Social Security # / Marital status
Address: / Home Phone:
Apt # / Cell:
City / State / zip / Work:
*Email:______
(Email will be used to register for Patient Portal, to access visits with Dr. Patel.) / How would you like to be notified for future appointments:
□Text
□Phone
How did you hear of us?
Pharmacy name:
Pharmacy Phone Number or Address (cross streets are fine):
(IF YOU DO NOT PROVIDE ONE, ONE WILL BE PROVIDED FOR YOU)
Emergency contact / Emergency contact #
Name of insurance:
Referring Physician: / Primary Care Physician:
Race:
□Asian
□Black or African American
□Hispanic / □White
□Other Race
□Refuse to Report
Guarantor: (Person to be billed, if different than patient)
Last Name: / First Name:
Birthdate: / Phone #
Patient’s or Authorized Person’s Signature
I the undersigned give my authorization to treat and assign directly to Nilesh Patel MD, all medical benefits, If any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved and covered charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. I understand that payment is expected at the time of service and diagnostic testing is a separate charge from the office visit.
Signature: / Date:
Please Attach all pertinent insurance ID cards for photocopying.
Nilesh Patel, M.D. PC
ACKNOWLEDGMENT AND CONSENT
By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the medical group listed at the beginning of this notice, and how I may obtain access to and control of this information. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protection that apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information from my Health Care Provider. Finally, by signing below, I consent to the use and disclosure of my health information to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operations of the medical group, its staff, and its business associates.
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Signature of Patient or Personal Representative
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Print Name of Patient or Personal Representative
______
Date