Physicians’ Wound Center

2770 Eureka Way, Suite 100

Redding, CA 96001

(530)241-2151 Fax: (530)241-2489

NEW PATIENT PAPERWORK

Name:______
(First) (Middle Initial) (Last)

SS#:_____-___-_____ DOB: ____-____-_____ Gender: Male or Female

Mailing Address:______City:______Zip:______

Home Phone:______Cell Phone: ______

Email Address: ______@______

Referring Physician: ______

Primary Care Physician: ______

Pharmacy: ______Street: ______City: ______

EMERGENCY CONTACT INFORMATION:

Name: ______Relation:______Phone:______

VOLUNTARY INFORMATION FOR MEDICARE REPORTING

Ethnicity: Hispanic/Latino Non-Hispanic/Latino Patient Declined

Race: American Indian/Alaskan Native American/Pacific Islander

Black/African American Multiracial Asian White

Preferred Language: English Spanish Other: ______

DO YOU HAVE HOME HEALTH? YES OR NO

If your answer was Yes-

Name of Home Health Agency: ______

Name of Home Health Nurse: ______

WHERE IS YOUR WOUND(S) ______

What treatments do you use on the wound(s)?

______

______

MEDICATIONS & PAST MEDICAL HISTORY

Drug & Food Allergies: ______

______

Please list all prescribed and over-the-counter medications you are currently taking.

Medication / Dose / Frequency

Please check any of the following that apply to you:

___Local Anesthesia Problems___Tuberculosis___Hepatitis

___Bleeding Tendencies___Leg Swelling___Herpes___Psoriasis ___Arthritis ___Keloids

___Eczema___Migraines/Headaches___Ulcers

___Neural Disease___HIV ___Hives___Hypertension ___Cancer: ___Lupus ___Poor Circulation ___Radiation/Chemotherapy ___Asthma ___Lung Disease ___Diabetes ___Anemia ___Hay Fever ___Seizures ___Thyroid ___Heart Disease/Murmur/Palpitation ___Hearing Problems ___Recent Weight Loss/Gain ___Kidney Disease/Stones/Recurrent Infections

Social History (please check all that apply)

___ Cigarettes ___ Alcohol ___ Coffee ___ Exercise ___ Recreational Drugs

Please list any Surgeries, Serious illnesses and/ or Hospitalizations:

CONSENT FOR TREATMENT AND BILLING

  1. I hereby authorize Physicians’ Wound Center or associates to perform upon me the named patient the following wound care and/or treatment: WOUND TREATMENT AND DEBRIDEMENT.
  2. The nature and purpose of the wound care and/or other treatment has been fully explained to me and I have been informed of the expected benefits and complications (from known and unknown causes), attendant discomforts and risk that may arise, as well as possible alternatives to the proposed treatment including no treatment. My questions have been answered fully and satisfactorily.
  3. Any tissues removed may be examined and retained by the Physicians’ Wound Center and its authorized affiliate for medical, scientific or educational purposes and such tissues or parts may be disposed of in accordance with accustomed practice.
  4. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the wound care and/or treatment.
  5. I herby consent that photographs, tape recordings, video tapes and/or movies may be taken of me, or the named patient, by Physicians’ Wound Center in connection with the medical and other services, which, I the patient am receiving at Physicians’ Wound Center. I further consent that a history of my/the patient’s social and medical problems may be taken by the Physicians’ Wound Center staff.
  6. I understand that neither myself/the patient nor members of my/the patient’s family will be identified by name in connection with any public use of this material.
  7. MEDICARE, I authorize any holder of medical or other information about me to release to the social security administration or its intermediaries or carries any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original request payment of medical insurance benefits either to myself of the party who accepts assignment.
  8. ALL OTHERS: I authorize any holder of medical or other information about me to release any information needed for this or a related claim. I permit a copy of this to be used in place of the original.
  9. I authorize payment of benefits to Physicians’ Wound Center. I understand I am financially responsible for charges not covered by this assignment, including coinsurance and deductibles.
  10. CANCELLATION POLICY: We require a 24-hour notice for all cancellations and/or rescheduling. A $30.00 cancellation fee will be charged for those who do not give proper notice. We are committed to your care and appreciate your commitment to us. This charge will not apply in some cases of emergency or illness.

I confirm that I have read and fully understand the above and that all blank spaces have been completed prior to my signing. I have crossed out any paragraphs that do not pertain to me.

______

Signature of Patient or Person Authorized to Consent for PatientDate

______

If Other than Patient, Relationship to PatientDate