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Southland Rheumatology New Patient Packet

Patient Name:


Patient Name:

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Gender:
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Marital Status:
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Race:
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Ethnicity:
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Language:
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Patient Employer


Patient Employer

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Person Responsible for Bill:


Person Responsible for Bill:

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Pharmacy Name:


Pharmacy Name:

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Permission to view Prescription History from External Sources:
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Primary Care Physician


Primary Care Physician

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Emergency Contact


Emergency Contact

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Insurance:


Insurance:

Primary Insurance
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Secondary Insurance
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Dr. Nayak is NOT a MEDICAID Provider.
FAILURE TO PROVIDE SECONDARY INSURANCE INFORMATION PRIOR TO VISITS WILL RESULT IN PATIENT BEING RESPONSIBLE FOR BALANCE ON ACCOUNT.

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

E-signature image
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Patient Medical History


Patient Medical History

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Please list any RECENT Blood Test, X-Rays, MRI’s, CT scans and Other Studies done in last 6 months and WHERE they were done?
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Do you have any allergies to medications?
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System Review


System Review

Please Check Any Symptoms You Are Currently Experiencing
Do you smoke?
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Do you drink alcohol?
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Do you use CBD?
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Have you had Osteoporosis Screening w/Bone Density Test?
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Have you had a Pneumonia Vaccination?
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Have you had COVID-19 Vaccination?
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Have you had Shingles Vaccination?
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Family Health History
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Is there a Family Medical History of:
Autoimmune Connective Tissue Disease like Lupus or Rheumatoid Arthritis?
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Osteoarthritis:
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Gout / Kidney Stones:
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Osteoporosis:
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Cancer:
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Heart Disease:
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Diabetes:
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