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Home
About
About
Video
Providers
Services
For Patients
Patient Resources
Cash/High Deductible Plan
New Patient Registration
New Patient Registration Form (Download)
Contact
New Patient Registration
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New Patient Registration
Step 1 of 6
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Name
First
Last
Other last names you have used
Social Security Number
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Driver's License
Race/Ethnicity
Martial Status
Single
Married
Divorced
Window/er
Sex
Female
Male
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Mailing Address (If Different)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Emergency Contact
Name
First
Last
Relationship
Primary Phone
Other Phone
Past Medical History
Previous Physician's Name
First
Last
Date of Last Exam
Date Format: MM slash DD slash YYYY
Have you ever been hospitalized?
Yes
No
If yes, what for?
Have you ever been tested for hepatitis A, B or C?
Yes
No
If yes, what for?
Have you been vaccinated for hepatitis A,B or C?
Yes
No
If yes, date vaccine series was completed
Date Format: MM slash DD slash YYYY
Last Tuberculosis (TB) screening
Date Format: MM slash DD slash YYYY
Result of TB screening
Positive
Negative
If positive TB screen, date of last chest x-ray
Date Format: MM slash DD slash YYYY
Result of Chest X-ray
Positive
Negative
Have you had a sexually transmitted disease?
Yes
No
Diagnosis
Which of the following conditions are you currently being treated or have been treated for in the past (Please Check)
Heart disease/Murmur/Angina
High Cholesterol
High blood pressure
Low blood pressure
Blood disorders/Anemia
Swollen Ankles
Heartburn (reflux)/ GERD
Shortness of breath
Asthma/ COPD
Tonsillitis
Sinus problems
Seasonal Allergies
Ear problems
Depression/ Anxiety
Eye disorder/Glaucoma
Seizures
Stroke
Headaches/ Migraines
Neurological problems
Psychiatric care
Cough
Diabetes
Kidney/ Bladder problems
Liver problems/ Hepatitis
Arthritis
Cancer/ Immunological disorders
Thyroid Problems
Ulcers/ Colitis
Please list past surgeries and procedures
Allergies
Do you have any food or drug allergies?
Yes
No
If yes, please list
Medications (Please include all your prescription medications, herbs, vitamins, supplements and aspirin)
List name, strength & frequency
Social and Preventive History
Do you currently smoke or chew tobacco?
Yes
No
if no, have you in the past?
Yes
No
How many packs per day?
Do you drink alcohol, beer, or wine?
Yes
No
if no, have you in the past?
Yes
No
How many drinks per week?
Do you currently drink coffee and/or tea?
Yes
No
if yes, how many cups per day?
Do you exercise daily/weekly?
Yes
No
Do you use seatbelts while driving?
Yes
No
Do you wear a helmet while riding a bike?
Yes
No
Family History
List living age (or age at death)/List serious illnesses
Mother
Father
Sibling 1
Sibling 2
Sibling 3
Females: Gynecological History
How many times have you been pregnant?
Date of last Pap smear
Date Format: MM slash DD slash YYYY
Have you had an abnormal Pap smear?
Yes
No
Diagnosis
Follow-Up
Have you had a sexually transmitted disease?
Yes
No
Diagnosis
Follow-Up
Date of last mammogram
Date Format: MM slash DD slash YYYY
Results
Normal
Abnormal
Were you biopsied?
Yes
No
Additional Screenings
Colonoscopy screening?
Yes
No
Date
Date Format: MM slash DD slash YYYY
Diagnosis
By signing below, I hereby certify that to the best of my knowledge all the information I have furnished on this form is complete, true and accurate.
Patient/Legal Guardian Initials
Date
Date Format: MM slash DD slash YYYY
Release of Medical Records Consent Form
Patients Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
SSN
All Records
Yes
No
Specific Records (please list below)
Yes
No
List records
Name of Previous Doctor(s) or Clinic(s)
Phone
Fax
Name of Previous Doctor(s) or Clinic(s)
Phone
Fax
Name of Previous Doctor(s) or Clinic(s)
Phone
Fax
Medical records can be faxed or mailed to:
Progressive Physician Associates (PPA) Health and Wellness Dr. Naja Thomas and/or Dr. Carl Middleton 4400 Heritage Trace Parkway Suite 204 Ft. Worth, TX 76244
Phone: 800.334.0150 | Fax: 817-502-3899
Patient's Initials
I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, sickle cell anemia, psychological or psychiatric impairments, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV).
Assignment of Insurance Benefits
I hereby authorize direct payment of my insurance benefits to PPA Health and Wellness or the physician individually for services rendered to my dependents or me by the physician or under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due.
Medicare/Medicaid Insurance Benefits
I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or my dependent’s records that these programs may request. I hereby direct that payment of my or my dependent’s authorized benefits be made directly to PPA Health and Wellness or the physician on my behalf.
Lab/X-Ray/Diagnostic Services
I understand that I may receive a separate bill if my medical care includes lab, x-ray, or other diagnostic services. I further understand that I am financially responsible for any co-pay or balance due for these services if they are not reimbursed by my insurance for whatever reason.
Acknowledgement of Potential Financial Interest in Ancillary Services
I acknowledge that my treating physician may have a financial interest in the overall performance of ancillary services as part of his/her affiliation with a group practice. I understand that I should contact my treating physician if I have any questions regarding his/her potential financial interest in the ancillary services. I further understand that I am free to choose where I receive medical services and that I may discuss with my physician the availability of alternative treatment facilities if I so desire.
Consent For Treatment
By signing this consent, I am authorizing my physician(s) and/or order another person to perform all exams, tests, procedures, injections, phlebotomy and any other care deemed necessary or advisable for the diagnosis and treatment of my medical condition. This consent is valid for each visit I make to Dr. Naja Thomas, M.D., MPH or Dr. Carl Middleton, M.D., MPH with PPA Health and Wellness or assigned physician in group unless revoked by me in writing and informed.
Date
Date Format: MM slash DD slash YYYY
Patient Initials
Office Policies
Refill Requests
Please allow 48 hours for refill. These request can be made by your pharmacy via fax or be left via voicemail. Please make sure that your pharmacy has the correct physician’s information. Same day refill requests are not guaranteed.
All controlled substances will be given in person only and will generaly require an office visit. The Physician maintains the right to refuse any request for prestcriptions that are medically inappropiate or unecessary and they also maintain the right to require a patient visit prior to rendering any prescriptions.
Referral Requests
If your insurance company requires a referral from your primary care physician for appointments with any specialist or procedures please allow 5 to 7 business days for this to be processed. Once your insurance has approved the referral , you will receive a letter in the mail with the information necessary to schedule the appointment.
Referrals will only be approved once your doctor has deemed it medically necessary and after a doctors visit. The patient has a right to choose the specialist, however they must be in your insurance’s network and it may delay the process for the referral. Please feel free to call the office to inquire about the status of your referral after 7 business days.
Phone Calls
Patients that no show to their appointments or do not cancel at least 24 hours in advanced will be charged a $20.00 fee.
Forms & Letters
There will be a $15 charge for all forms, letters and any other paperwork that will need to be completed by the physician.The physician will have the right to decline to do so if it not deemed medically necesarry. The fee is to be paid prior to the completion of the forms. Please allow at least 72 hours for the completion, this includes but is nit limited to FMLA, Home Health Certifications, Drug Discounts and Temporary Leave Paperwork.
Patient Portal
Please give your email address so that we can provide you a link to access your lab results online.
Release of Patient Information
Untitled
First Choice
Second Choice
Third Choice
I CONSENT AND AUTHORIZE THE RELEASE OF ANY NORMAL OR ABNORMAL TEST RESULTS OR IMAGING RESULTS BY PHONE TO THE FOLLOWING PERSONS:
My Spouse
My Children
My Parents
My Voicemail
All
Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Initials
Date
Date Format: MM slash DD slash YYYY
IN GENERAL, THE HIPAA PRIVACY LAW GIVES PATIENTS THE RIGHT TO REQUEST ON USES AND DISCLOSURES OF THEIR PROTECTED HEALTH INFORMATION (PHI). THE PATIENT IS ALSO PROVIDED THE RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS OR THAT A COMMUNICATION OF PHI BE MADE BY ALTERNATIVE MEANS, SUCH AS SENDING CORRESPONDENCE TO AN OFFICE INSTEAD OF A HOME ADDRESS. THE INFORMATION WILL REMAIN IN EFFECT UNTIL REVOKED IN WRITING BY THE INDIVIDUAL.
Home Telephone
Ok to leave message with detailed information
Leave name/Doctor with callback number only
Work Telephone
Leave detailed message on work voicemail
When unable to contact me by phone, written communication may be sent to my home address
Other
If other, please explain
Patient Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Patient Initials
Date
Date Format: MM slash DD slash YYYY
HEALTHCARE PROVIDERS MUST KEEP RECORDS OF PHI DISCLOSURES. INFORMATION PROVIDED WILL BE DOCUMENTED ON THE TEST RESULT, PROGRESS NOTE OR PAATIENT COMMUNICATION IN QUESTION.
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