Sound Health Services


New Patient Form

 
Patient Information
 
Marital Status



Language











 
Race







 
Ethnicity


Preferred Phone Contact    


Okay to Receive Text Messages

How did you hear about us?





Guarantor Information (person bringing in minor)
Insurance Information
Do you have healthcare insurance?

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.
 
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).
 

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.
 

HIPAA Information
  1. 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*
     
  2. Person(s) authorized to discuss/receive any information listed above and relationship to patient.
     
     
  3. Authorization for Leaving Messages
Information regarding appointments
Answering Machine?  
Office Voicemail  
With Person Named Above?  
Mail?  
Information regarding ALL other medical information
Answering Machine?  
Office Voicemail  
With Person Named Above?  
Mail?  
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).
 
Authorization for Release of Information
Authorization for the Release of Protected Health Information for Continuity of Care
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.
 
Medical History Questionnaire
History of Present Illness
Past Medical History
Have you been diagnosed with any of the following - check all that apply    






      

      








      
      





      








      
Past Surgical History
Check all that apply    
ENT Surgery


      


      





      
Other Surgery


Current Medications
Do you currently take ANY medication?*

Drug Allergies?*

Latex Allergy*

Pet Allergies?*

History of Anesthesia Problems?*

Social History
Flu Shot

Pneumonia Shot

COVID-19 Vaccine

Tobacco Use*

Do you use alcohol?*


Family Medical History
Do any family members have any of the medical problems below?    
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
 













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.
 
LuxSci helps ensure HIPAA-compliance for email and web services.