Patient Registration

Referred to this office by

Address

City

State

Zip

Patient Name – First

Last

Gender
Male Female

Address

Apt.

City

State

Zip

Home Phone

Cell Phone

Birthdate

Age

Social Security No.

Email Address

Marital Status
Single Married Widowed Divorced

Patient’s Employer

Occupation

Address

City

State

Zip

Spouse or Next of Kin Name

Birthdate

Phone

Social Security No.

Employer

Occupation

Address

City

State

Zip

Specific reason for seeing Dr. Barnthouse

Have you consulted other doctors for this?
Yes No

Primary Care Physician Name

Location

Patient Height

Weight

Significant weight change
Gain Loss

How much?

Please list any significant or unusual medical problems

Do you have, or have you had

Heart Disease
High Blood Pressure
Stroke
Diabetes

Seizures
AIDS or HIV+
Hepatitis
Kidney Disease

Asthma, Pneumonia
Rheumatic Fever
Arthritis
Bleeding Tendency

Jaundice
Psychiatric Illness
Thyroid Disease
Mitral Valve Prolapse

Explain any items above

Previous surgeries (include year)

Describe any surgical complications

Allergies to any medication
Penicillin
Sulfa
Other
None

Medicines you take

Birth Control Pills
Heart Medication
High Blood Pressure Med
Diuretics (water pills)

Insulin, Diabetic pills
Dilantin, Phenobarbital
Blood Thinner Meds
Aspirin

Ibuprofin (Motrin®)
Tranquilizers
Steroids, Cortisone (last 6 mos.)
Hormones

Other medications

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.

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):

Name

Relationship

Phone

Name

Relationship

Phone

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.

Date

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

Patient Registration

HIPAA Compliance Patient Consent

HIPAA Compliance
Patient Consent