PATIENT REGISTRATION (Please Print Clearly)

PATIENT REGISTRATION (Please print clearly)

Name: ______

Male/Female: _____ SSN: ______Date of Birth: ______Age: ______

Mailing Address: ______

City: ______State: ______Zip: ______

Physical address: ______

City: ______State: ______Zip: ______

Home Phone: ______Cell: ______Work: ______

E-mail address: ______

Best way to reach you: □Home □Cell □Work Can we leave a message? □Y □N

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

Ethnicity: □Hispanic or Latino □Not Hispanic or Latino □Other □Declined

Race: □Am Indian □Asian □Black □White □Other □Declined

Preferred Language (if other than English): ______

Please list any communication barriers (deafness/blindness): ______

Emergency Contact/Relationship: ______Phone: ______

Guarantor of Bill/Relationship: ______Phone: ______

Insurance Carrier/Employer: ______

Policy Holder’s Name: ______DOB: ______SSN: ______

Please present insurance card for copying. Payment is expected at time of service.

Do not hesitate to speak to us now if this is a problem.

Authorization of Release of Information

Lillington Family Medical Center may disclose all or part of this patient’s record to any insurance company or association and the Federal or State Government. Such information may be necessary for the completion of all clinic claims. I understand that the information to be released may include information pertaining to mental health or psychiatric related conditions and/or alcohol abuse. A copy shall be valid as the original.

Assignment of Benefits

I hereby authorize Lillington Family Medical Center benefits herein specified and otherwise payable to me for any services rendered by the clinic subsequent to this date and for such other charges as may be made by said clinic. I hereby agree to pay the same and also agree that in the event of medical coverage is sufficient to pay the indebtedness incurred and should there be any money over and above that is necessary to pay this registration, I agree that said clinic may apply coverage against any amount which is owed by myself, my spouse, or legal dependents of myself and my spouse at the time to Lillington Family Medical Center.

I certify the information given by me in applying under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or related medical claims. I request that payment of Authorized Benefits be made on or in my behalf to Lillington Family Medical Center. A copy should be valid as the original.

I, the undersigned, certify that I have read the foregoing, and am the patient, or am duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.

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Signature/Date

ADULT PAST MEDICAL HISTORY

Pharmacy: ______

Chronic Medical Problems: ______

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Current Medications: ______

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Drug Allergies: ______

Hospitalizations or Surgeries: ______

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Please List Any Specialty Providers You May See: ______

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Vaccines:(when was your last…?)Preventative Procedures:(when was your last… and where…?)

Tetanus: ______Physical Exam: ______

Flu: ______Colonoscopy: ______

Pneumonia: ______Mammogram: ______

Zostavax: ______Pap Smear: ______

Gardasil (HPV): ______Dexa (Bone Density): ______

Menactra (Meningitis): ______Eye Exam: ______

SOCIAL HISTORY

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

Occupation: ______Spouse’s Name: ______

Number of Children: _____ Level of Education: □High School □GED □College ______

Lillington Family Medical Center

PO BOX 1687

7 East Duncan St.

Lillington NC 27546

Phone: (910) 893-2641 Fax: (910) 893-3208

John L. Briggs, MD Jessica M. Sloan, MD

Request for Limitations and Restrictions of Protected Health Information

Patient Name: ______Date of Birth: ______

Patient Address: ______

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The following person(s) have my permission to obtain any information, medical or general in reference to my care: (ex: appointment information, discuss medications or treatment)

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The following person or person(s) have my permission to pick up any prescriptions or medical forms:

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Signature of Patient or Legal Guardian: ______

Date: ______

LILLINGTON FAMILY MEDICAL CENTER

John L. Briggs, MD Jessica M. Sloan, MD

NO SHOW POLICY

A pattern of repeated “no shows” for appointments will result in dismissal from this medical practice. A “no show” is defined as a missed appointment in which the individual does not call to cancel or reschedule the appointment time. We request at least 24 hour notice for any cancellations. A $25.00 fee will be charged for each no showed appointment and must be paid on or before the next visit.

Our staff calls and reminds patients two days ahead of time for appointments. It is the patient’s responsibility to make sure we have the right phone number in his or her chart.

Your signature below indicates that you aware and understand this policy. Should you have any questions, please direct them to the office manager. If you should refuse to sign this form, a blank form with the refusal date will be placed in your chart.

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Patient/Guardian Signature Date