Patient Registration Form - Primary Health Medical …
Patient Registration Form Patient Information M.I.: Mailing Address: Apt #
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PATIENT INFORMATION SHEET - Primary Health
www.primaryhealth.comPATIENT INFORMATION SHEET NAME: GENDER: DOB: DATE: ALLERGIES: List ALL MEDICATIONS you take, including over-the-counter (OTC) medications and vitamins. Include specific doses and when tak e n. I fyoud o’ tkn w, pl as cl rph mis i . PERSONAL MEDICAL HISTORY: (Please circle all that apply)
Routine Preventive Exams (Annual Physicals)
www.primaryhealth.com2. When you talk with your provider, let them know you are there for your routine preventive exam. 3. If you bring up health problems during your routine preventive exam, understand that you may have a charge related to the treatment of that problem, or the provider may ask that you schedule a separate appointment for evaluation of that problem. 4.
Patient Registration Form - Primary Health Medical Group
www.primaryhealth.comI certify that I have read and agree to Primary Health Medical Group's (PHMG) payment policy. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to PHMG all money to which I am entitled for medical expenses related to the services performed ...
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