Patient Registration

Gender   
Male    Female   

Marital Status   
Single    Married    Widowed    Divorced   

Have you consulted other doctors for this?   
Yes    No   

Pharmacy Name  

Pharmacy Phone  

Pharmacy Address  

City  

State  

Zip  

Significant weight change   
Gain    Loss   

Allergies to any medication
Penicillin    
Sulfa    
Other    
None    

Are you presently pregnant?     
Yes    No   

Do you smoke?     
Yes    No   

Have you been treated for alcohol or drug abuse?   
Yes    No   

I give the office of Dr. Barnthouse permission to leave messages at my work, my home, my cell phone, or on voice messages at these place requesting a return call to "Dr. Barnthouse's office".

HIPAA Compliance
Patient Consent

Our notice of privacy practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

By signing this form, you consent to our use and disclosure of your protected healthcare information. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information rnay be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The patient has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

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In addition, I give my consent for Dr. Barnthouse and staff to communicate/discuss/share protected health information about me with the following individual(s):

Signature of Patient or Legal Guardian – 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.