3365 Burns Rd Suite 217 Palm Beach Gardens, Fl 33410

Phone (561) 627-7433 Fax (561) 775-1055

Afterhours Number (561) 881-3165

Phone hours 9:00 am -4:00 pm

Welcome to Gardens Family Practice! We care happy to have you join our family and would like to give you some general information regarding our office and staff. We are a small office with only one location. We have three physicians who have over 60 years’ experience combined. You also can reach a physician 24/7 by calling the after hour’s number listed above.

Meet the Physicians:

Prabhavathi Viralam MD she is Board certified in Family Practice she has been practicing in Palm Beach Gardens since 1995. Eduardo Sequeira MD he is Board Certified in Internal Medicine he has been practicing since 1984.

Gabriele Knaus MD she is Board Certified in Family Practice she has been practicing since 1991.

Office Hours: / Appointment Time: / Appointment Availability:
Monday- Thursday 8:30am- 4:00 pm / Morning Appointments 8:45 am -11:00 am / Monday, Tuesday, Thrus: Am/PM
Friday 8:30- 12:00 noon / Afternoon Appointments 1:00 pm- 3:00 pm / Wednesday: Afternoon Only
Lunch daily 12:00-1:00pm / Friday: Morning Only

We see patients by appointment ONLY. We offer urgent appointments on a same day basis. Sick appointments are seen within 3 days. All new patients and well exams scheduled within one month. However, we try and accommodate every appointment as soon as possible.

We will only have one physician in the office each day if you want to request an appointment with a particular doctor we will offer the first available.

E-mail:

Appointments/General Information:

Medication refills/Questions for the doctor or nurse: eferrals/Reach the office manager:

Visit our website at request refills, appointments and referrals. Also you can submit e-mail requests directly to the office staff.

Office Policy’s:

Referrals must be requested 48 hours in advanced.

Medication refills must be requested 1 week prior to running out of medication please.

Missed Appointments: $25 fee on appointments not cancelled or rescheduled within 24 hours or No call no show appointments Notice of Privacy Policy is available upon request. A copy is also available on our website

Co-Pays/Deductibles are due at the time services are rendered. We except Visa, Master Card, Discover Card, Cash and Checks. If a check is declined there is a $25 returned check fee and we can no longer accept checks as a form of payment.

You will be scheduled with which ever provider is scheduled the day of your appointment unless you request a specific provider. In that case we will attempt to accommodate as best as we can.

Our staff is always available to answer any question you may have. On Monday mornings, please limit calls to urgent matters only because we have a large call volume on that day. All Calls are returned SAME DAY. We handle each request to the best of our abilities and as efficiently as possible.

PATIENT INFORMATION
First Name / Last Name / Middle Initial
Address / City / State / Zip
Home Number / Mobile Number / Other / Date of Birth / SSN: / Gender
☐ Male☐Female
Please indicate your preferred telephone contact number Mobile / Home /Work / MaritalStatus☐Married☐Single
☐Divorced☐Widow/Widower
Patient’s E-mail / Do you agree to contactbye-mail?Yes /No
Race (checkone)☐White☐ Black/AfricanAmerican
☐Asian☐Hispanic☐ White/Non-Hispanic
☐Other / Ethnicity☐Hispanic☐Non-Hispanic
INSURANCE INFORMATION
(If you’re not primary)
Primary Insurance
(ex Humana, BCBS etc.) / Policy Number
Patient’s relationshiptosubscriber:☐Self☐ Spouse ☐Child
Name of secondary insurance (if applicable) / Policy Number
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address) / Relationship to patient / Phone Number
PHARMACY INFORMATION
Pharmacy Name / Number / Address
GENERAL INFORMATION
DO YOU HAVE A LIVING WILL?(a statement of what medical treatment you would not want in thefuture?)Yes /No
Have you nominated someone to speak on your behalf (e.g. a person who has PowerofAttorney)?Yes /No
If “Yes”, please state their name, address & phone no:
Your Previous Doctor Name & Address: / Who referred you to our office?
CONSENTS
I consent to Gardens Family Practice to receive medication history from the Pharmacy / Yes / No
I consent to Gardens Family Practice send and receive electronic correspondence to me / Yes/ No
I consent to Gardens Family Practice to leave Protected Health Information on voicemail / Yes / No

Dear Patient:

Due to the high cost of medical billing, payment is requested at the time of treatment, unless payment plan arrangements are made with the doctor or billing manager, your signature indicated agreement with the following stipulations:

1.Payment in full at time of visit. (If no insurance coverage at all) including applicable insurance co-payment. Patients with indemnity coverage (80/20 plans) will be responsible if deductible has not been met and/ortheir 20% at time ofservice.

2.If payment is not received by your insurance company for any reason within 90 days, you will be responsiblefor the full amountdue.

3.The signing party will incur all costs including collection fees, court costs, and reasonable attorneys’ fees, if payment not received asdescribed.

4.Any secondary or supplemental insurance claims that need to be filed will be done as a courtesy to ourpatients.

All remaining balances after claims are processed are the sole responsibility of the patient!

5.Managed care subscribers (HMO, PPO, POS) Florida State Law requires payment by your insurance carrier to the participating provider within 60 days of the submission of the medical claim. If the claim is not paid, your insurance company has broken its contractual agreement. Since this is your insurance; if the claim is not paid by your insurance carrier, then it is your responsibility to pay the claim or have it paid by the insurancecompany.

6.There will be a fee of $25 for an appointment not canceled within 24 hours in advance and no call no showvisits.

Thank you very much for your understanding and cooperation.

CONSENT FOR TREATMENT.

I voluntarily consent to the rendering of medical care by Gardens Family Practice PA physicians. I understand that I am under the care and supervision of my attending physician and it is the responsibility of the staff to carry out the instructions of the physician.

PatientSignature:

AUTHORIZATION TO RELEASE INFORMANTION:

Date:

I authorize Gardens Family Practice PA to release any and all information acquired in the course of my examination and/or treatment for the purpose of insurance, workman’s compensation or Medicare benefit payments.

PatientSignature:Date:

Medical History
Name / Date of Birth / Age / Date
Why are you here to see the doctor: (ex sick, wellness etc):
ALLERGIES / SURGERIES
(List any allergies to medicines or other substances) / ☐None / Date / Reason / ☐None
MEDICAL PROBLEMS/ HOSPITALIZATIONS / MEDICATION
List any chronic or recurrent medical problem / ☐None / Prescription and non-prescription / ☐None
NameDoseFrequency
REVIEW OFSYSTEMS
(check any that you have had or nowhave)
ENT / KIDNEYS
Difficulty Swallowing / Hearing Problems / Bladder infections / Kidney Disease
Frequent Sore Throat / Nosebleeds / Diabetes (Type 1 or Type 2) / Urinating Frequently
Frequent Earaches / Ringing in the Ears / Frequent/Painful urination / Urinary Incontinence
Frequent Sinus Problems / Sinusitis / Blood in urine / Other:
RESPIRATORY SYSTEM / CARDIOVASCULAR SYSTEM
Asthma / Pleurisy / A-Fib / Heart Murmur
Bronchitis-Recurrent / Pneumonia / Abnormal EKG / Heart Disease
COPD / Shortness of Breath / Congestive Heart Failure / High Blood Pressure
Coughing Blood / Sleep Apnea / Chest Pain / Low Blood Pressure
Cystic Fibrosis / Frequent Chest Infections / Fluttering / High Cholesterol
Emphysema / Other: / Heart Attack / Irregular Heartbeat
GASTROINTESTINAL / NERVOUS SYSTEM
Abnormal Colonoscopy / Crohn’s Disease / Blurred Vision / Migraine Headaches
Blood in Bowel Movements / Gallstones / Head Injury’s / Meningitis
Difficulty Swallowing / Hepatitis / Epilepsy / Stroke
Cirrhosis / Irritable Bowel Syndrome / Fainting / Seizures
Colitis / Pancreatitis / Headaches / Persistent Numbness
Constipation / Ulcer / Other: / Paralysis
OTHER / OTHER
Anemia (low Iron) / Gout / Rheumatoid Arthritis / Pulmonary Embolism
Arthritis / Lupus / Thyroid Disease / Deep Vein Thrombosis
Unexpected Weight loss / Clotting Disorder / Personal History of Cancer:

PatientName:

IMMUNIZATION HISTORY / PREVENTIVE CARE
Date of last shot / Colorectal Disease Screening / Y / N / When/Where
Influenza (Flu) Vaccine / Colonoscopy
Shingles Shot (Zostavax) / Stool Cards
Tetanus/Diphtheria (Td) / Diabetes Management
Tetanus/Diphtheria and Pertussis (Tdap) / Diabetic blood work
Pneumococcal Vaccine / Diabetic Eye Exam
Pneumovax 23 (PPSV23) / Diabetic Foot Exam
Prevnar 13 (booster) PCV13 / Other
Hepatitis B Vaccine / Yearly Eye Exam
Hepatitis A Vaccine / Mammogram
Bone Density
Prostate Cancer Screening
FAMILY HISTORY / PERSONAL HISTORY
☐None ☐ Adopted (unknown) ☐ Adopted someknown / For Woman Only
Condition (Blood Relative) / Relation to self / Menstruation
Alcohol/Drug Abuse (circle one) / Age periodsbeganHow Often:
Asthma / Date of last menstrual period: (Best guess)
Allergies / Now Pregnant? ☐ Yes ☐ No
Diabetes (Type 1 / Type 2) (circle one) / Menopause?
Glaucoma / Unexplained Vaginal Bleeding? ☐ Yes ☐ No
Heart Disease / Date of Last Pap Smear?
High Blood Pressure / PREGNANCIES
High Cholesterol / Total number of pregnancies?
Kidney Disease / Total Births?
Sickle Cell Condition / Miscarriages?
Thyroid Disease / For Men Only
List All Cancers / ProstateTrouble☐ Yes ☐No
Other / Dischargefrompenis?☐ Yes ☐No
Erection/Impotence?☐ Yes ☐No
SOCIAL HISTORY
Your Occupation: / Exposed to hazardous substances ☐ Yes ☐ No
If yes, please list:
Tobacco Use / Alcohol Use
Doyousmoke?☐Yes☐No☐Ex-Smoker / Do youdrink alcohol?☐Socially☐No
☐RecoveringAlcoholic
How much do/did you smoke per day? / How much do/did you drink per day?
How long have you smoked? (years) / HistoryofAlcoholism☐ Yes ☐No
When did you quit? / If yes, how long have you been in recovery?
Drug Use
Drug abuse, if so what? / If yes, how long have you been in recovery?

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

To Family/ Friend or Personal Representative

PatientName:

Please Print Name

Patient’s Date ofBirth:

Person(s) authorized to receive the information upon my behalf:

E.G., Spouse’s Name and Phone Number, Family member’s Name and Phone Number, Employer


Specific description of the information that may be used or disclosed (including dates):

E.G., Full Chart, Specific Date of Service


HOME#,CELL#, and/ or WORK#

1)I understand that this authorization will expire one year from today’sdate.

2)I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on this signed authorization) at any time by notifying Gardens Family Practice PA inwriting.

3)I understand that I can refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment or my eligibility for benefits (ifapplicable).

4)I may inspect or copy any information used or disclosed under thisagreement.

5)Iunderstandthat,ifthepersonororganizationthatreceivesthe informationisnotahealthcare providerorplancoveredby federal privacy regulations, the information described above may be re-disclosed and would no longer be protected by these regulations.



Patient’s Signature orPatient’sRepresentativeDate



Printed Name ofPatient’sRepresentativeRelationship toPatient