New Patient Form
Patient Information
Last Name
*
First Name
*
MI
Date of Birth
*
Sex
*
Last 4 digits of SSN
*
Marital Status
Single
Married
Divorced
Widowed
Language
Arabic
Chinese
English
French
German
Mandarin
Spanish
Vietnamese
Decline
Other
Other Language
Race
African American
American Indian or
Alaska Native
Asian
Caucasian
Hispanic/Latino
Native Hawaiian or
other Pacific islander
Declined
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Declined
Home Phone
*
Work Phone
Mobile Phone
Preferred Phone Contact
Home
Work
Mobile
Okay to Receive Text Messages
Yes
No
Email Address
Address
*
City
*
State
*
Zip
*
Please select your provider below
*
Frederic A. Pugliano, MD
Sean B. Bailey, MD
Rebecca M. Brandsted, MD
Unknown
Preferred Local Pharmacy
*
Phone Number
Referring Physician
Primary Care Physician
How did you hear about us?
Flyer
Insurance
Radio
Facebook
Patient
Other
Guarantor Information (person bringing in minor)
Guarantor Name
Date of Birth
Sex
Relationship
Billing Address
(if different from above)
City
State
Zip
Home Phone
Mobile Phone
Insurance Information
Do you have healthcare insurance?
Yes
No
Primary Insurer Name
Subscriber/Policy Number
*
Last Name
*
First Name
*
MI
Date of Birth
*
Sex
Relationship to Patient
Billing Address (if different from above)
City
State
Zip
Home Phone
Mobile Phone
Do you have secondary healthcare insurance?
Yes
No
<
Secondary Insurer Name
Subscriber/Policy Number
*
Last Name
*
First Name
*
MI
Date of Birth
*
Sex
Relationship to Patient
Billing Address (if different from above)
City
State
Zip
Home Phone
Mobile Phone
I certify this information is true and correct to the best of my knowledge. I will notify you of any changes to the above information. I authorize the release of any medical information necessary to process an insurance claim and request payment of benefits be made to the physician unless my account has been paid in full.
I have received Sound Health Services, P.C. Notice of Privacy Practices.
Responsible Party Signature
*
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Financial Agreement and HIPAA Release
Statement to Authorize Payment of Insurance Benefits, Release of Information and Billing Terms
I certify that the information given by me in applying for payment under my insurance contract is correct. I authorize any holder of medical information about me to release to my insurance carrier and/or
Sound Health Services, PC
, any information required to process my insurance claims or complete my medical record. I request that payment under the medical insurance program be made to
Sound Health Services, PC
for services provided to me for the duration of my medical treatment. If your account is not paid for in full within the 90-day billing cycle, your account may be referred to our collection agency for further action. As a courtesy,
Sound Health Services, PC
, will attempt to contact you by phone, email or mail informing you of your account. After your account is reported to our collection agency, you may pay your bill directly to the collectors. Any cost for collection of the unpaid invoice including, but not limited to, collectors fees, legal fees and disbursements will be the obligation of the person named on the invoice or other responsible party.
Signature
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature (Must be 18 years of age to sign).
Date
Statement to Authorize Payment of Medicare Benefits
I certify that the information given to me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical information about me to release to the Social Security Administration, or its carriers, any information required to process any Medicare claims. I request that payment under the medical insurance program be made to
Sound Health Services, PC
for services provided to me for the duration of my medical treatment.
Signature
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
HIPAA Information
I acknowledge that I have been given the opportunity to read and/or receive a copy of the Sound Health Services, PC
Privacy Notice
.
*Available to view online or request at the front desk*
Person(s) authorized to discuss/receive any information listed above and relationship to patient.
Name
Relationship
Name
Relationship
Authorization for Leaving Messages
Information regarding
appointments
Answering Machine?
Yes
No
Office Voicemail
Yes
No
With Person Named Above?
Yes
No
Mail?
Yes
No
Information regarding
ALL other medical information
Answering Machine?
Yes
No
Office Voicemail
Yes
No
With Person Named Above?
Yes
No
Mail?
Yes
No
Signature
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature (Must be 18 years of age to sign).
Date
Authorization for Release of Information
Authorization for the Release of Protected Health Information for Continuity of Care
Patient Name
*
Maiden Name
(if applicable)
Date of Birth
*
Home Phone No.
Patient Representative (if patient is minor):
Relationship
The consent below will allow Sound Health Services, PC to send and/or receive medical records on behalf of myself for the purpose of continuity of care.
The following consent will be good for 1 year from the signature below.
I,
hereby consent to have my medical records sent and/or received by Sound Health Services, PC on my behalf for the purpose of continued medical care or for personal use.
I understand that these records may be sent by mail, electronically or via fax.
I understand that these records will include my entire medical record to date, except for any records ordered or sent by outside providers other than Sound Health Services, PC and that they will not include any financial information.
I understand that this release will not be authorized for use for 3rd party requests such as but not limited to: Social Security Claims, Insurance Claims, Litigation Claims, but solely for the purpose of provider to provider or for personal use only.
I understand that my medical /health information records are confidential. I understand that by signing this authorization I am allowing the release of all medical information up until the expiration of this release, unless otherwise indicated. The PHI in my medical record may include mental/behavioral health information. In addition, this may also include information regarding sexually transmitted diseases, HIV and/or other communicable diseases.
I understand that I may revoke this authorization at any time. I may request a copy of any records released on my behalf for review. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure, and the information may not be protected by federal confidentiality laws.
Patient or Patient Representative Signature
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
Date
Medical History Questionnaire
Patient Name
*
Age
Date of Birth
*
Sex
*
Primary Care Physician
Referred by
Pharmacy Name
Phone
Zip
Nature of Visit
*
– Chief Complaint (reason for this visit)
History of Present Illness
Symptoms
When Symptoms Started
Quality
(Dull/Throbbing/Sharp?)
Severity
(Mild/Moderate/Severe?)
Context
(Better/Worse/Chronic?)
Timing
(Daily/With Activity/At Night?)
Duration
(How long does it last?)
Associated Symptoms
Past Medical History
Have you been diagnosed with any of the following - check all that apply
None apply
Allergies
Aneurysm
Arthritis
Asthma
Autoimmune Disorder
Bleeding Disorder
Cancer
Cataracts
Cerebral Palsy
COPD/Emphysema
Diabetes
GERD/Reflux
Glaucoma
Head Injury
Hearing Loss
Heart Disease
Hepatitis
A
B
C
HIV
Hypertension/High BP
Kidney Disease
Lung Disease
Mental Disorder
Migraines
Pacemaker
Sleep Apnea
Stroke
Thyroid Disorder
Tinnitus
Vitamin D Deficiency
Other - enter below
Past Surgical History
Check all that apply
None apply
ENT Surgery
Adenoidectomy
Ear Surgery
Ear Tubes
Facial Plastic Surgery
Nasal/Sinus
Thyroid
Tonsillectomy
Other ENT (enter below)
Other Surgery
Current Medications
Do you currently take ANY medication?
*
Yes - enter name, dosage and frequency
No
Drug Allergies?
*
Yes - enter name and reaction
No
Latex Allergy
*
Yes
No
Pet Allergies?
*
Yes
No
List Type
History of Anesthesia Problems?
*
Yes
No
List Type
Social History
Occupation
Flu Shot
Yes
No
Date of Shot
Pneumonia Shot
Yes
No
Date of Shot
COVID-19 Vaccine
Yes
No
Date of Shot
Tobacco Use
*
Yes
No
Select type
Cigarettes
Vape
Cigars
Pipe
Snuff/Chew
Started Smoking
Quit Smoking
Packs per Day
Total Years Smoking
What year did you quit?
How many years did you use tobacco?
Do you use alcohol?
*
Yes
No
Quit
Alcohol frequency
What year did you quit?
How many years did you drink?
Family Medical History
Do any family members have any of the medical problems below?
None apply
Asthma
Bleeding Disorder
Cancer
Diabetes
Hearing Loss
Heart Disease
High Blood Pressure
Kidney Disease
Liver Disease
Stroke
Review of Current Symptoms
Check any of the following that apply to you today
Allergies
Cough
Dizziness
Ear Drainage
Ear Pain
Hearing Loss
Tinnitus
Vertigo
Loss of Smell
Nasal Congestion
Nasal Drainage
Nosebleeds
Hoarseness
Reflux/GERD
Sore Throat
Fatigue
Sleep Apnea
Snoring
Signature of Patient or Responsible Party
*
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date