NEW PATIENT PACKET

1 NEW PATIENT PACKET PATIENT s Name: _____ Last Middle First Address: _____ City: _____ State: _____ Zip: _____ Home Phone: _____ Cell Phone: _____ Primary Contact: Home Phone Cell Phone Email Address: _____ Driver s License #: _____ DOB: _____ Gender: Male Female Social Security #: _____ Employer: _____ Work Phone: _____ Race: White Hispanic Black or African American Asian Decline to Report Other: _____ Ethnicity: Hispanic or Latino/a Not Hispanic or Latino/a Decline to Report Other: _____ Whom may we call in Case of Emergency?

2 Name: _____ Relationship to PATIENT : _____ Primary Phone #: _____ PracticePolicy contractedwithtocollectcopayments, ,the ;however,itisyour signatureand$ refilled on the next business day. All refills must be done before Friday at noon. Canceling/ReschedulingAppointments :Ifyouareunabletokeepyourappointment,ple asenotifyourofficeatleasttwenty fourhoursinadvance appointment time.

3 patients will be charged $ for missed appointments unless the appointment was cancelled 24 or more hours in advance. Whatifmychildneedstoseeaprovider? Aparentorlegalguardianmustaccompanypatie ntswhoareminorsonthepatient accompanying adult is responsible for payment on the account. PATIENT s Initials: _____ Insurance Information Primary Insurance Company : _____ Insurance Phone: _____ Insured Name: _____ DOB: _____ SS#: _____ PATIENT Relationship to Insured: _____ Insurance ID#: _____ Group#: _____ Address of Insured: _____ Secondary Insurance Company : _____ Insurance Phone: _____ Insured Name: _____ DOB: _____ SS#: _____ PATIENT Relationship to Insured.

4 _____ Insurance ID#: _____ Group#: _____ Address of Insured: _____ Lonestar Medical 952 Gruene Road, Ste. 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 Consent for Purpose of Treatment, Payment, Health Care Operations and Notice of Privacy Practices Iconsenttotheuseordisclosureofmyprotecte dhealthinformationbyLonestarMedical,fort hepurposeofdiagnosingor providingtreatmenttome, , ,JanDubensky, ,orSueBrandt, upon my consent as evidence by my signature on this document.

5 IunderstandIhavetherighttorequestarestri ctionastohowmyprotectedhealthinformation isusedordisclosedtocarry outtreatment, ,ifLonestarMedicalagreestoarestrictionth atIrequest,therestrictionisbinding between Lonestar Medical and _____. (Write PATIENT s name here) Ihavetherighttorevokethisconsent,inwriti ng,atanytime, , ,JanDubensky, , Sue Brandt, , or Lonestar Medical has taken action in reliance on the consent. My ProtectedHealthInformation meanshealthinformation,includingmydemogr aphicinformation,collectedfromme andcreatedorreceivedbymyphysician,anothe rhealthcareprovider,ahealthplan,myemploy erorahealthcare ,present,orfuturephysicalormentalhealtho r condition and identifies me or there is a reasonable basis to believe the information may identify me.

6 IunderstandIhavearighttoreviewLonestarMe dical myprotectedhealthinformationthatwilloccu rinmytreatment,paymentofmymedicalclaimso rintheperformanceof my protected health information. arevisedNoticeofPrivacyPracticesbycallin gtheofficeandrequestingarevisedcopybesen tinthemailoraskingforone at the time of my next appointment. _____ Signature of PATIENT or Personal Representative Name of PATIENT or Personal Representative _____ Date Description of Personal Representative s Authority I am giving authorization to Lonestar Medical to disclose my medical and insurance information to the below person(s).

7 _____ _____ Person(s) to whom information may be disclosed Person(s) to whom information may be disclosed _____ Signature of PATIENT or Personal Representative Date Lonestar Medical 952 Gruene Road, Ste. 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 PATIENT INTAKE FORM Name : _____ Date of Birth : _____ Date of Encounter : _____ Reason for visit / Current Problem : _____ _____ Allergies ?

8 Yes or No If yes, what? _____ Asthma ? Yes or NoDiabetes ? Yes or No List of Medications : Past Medical History : _____ _____ Surgical Medical History : _____ _____ Family History : _____ _____ Social History : Smoker? Yes or No If yes, how long? _____ Quantity: _____ Alcohol? Yes or No If yes, how often? _____ Marital Status : Married Single Divorced Widowed Exercise?

9 Yes or No If yes, how often? _____ Recreational Drug Use? Yes or No If yes, how often? _____ Staff Initials and Date: _____ Lonestar Medical 952 Gruene Road, Ste. 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 OFFICE AND COLLECTION POLICIES Office Visits you the highest quality of care. atleastthreehours priorthe scheduledappointmenttimemaybesubjecttoac ancellationfeeof$ $ $ require more than a signature and for writing letters each time these services are provided.

10 Always bring a current list of all your medications with the exact dosages to each office visit. Office Hours Monday Thursday: 8:30am 5:00pm and Friday: 8:30am 3:00pm (closed for lunch most days 12:30pm 1:30pm) Allergy shot patients must come in no later than 30 minutes prior to closing. Telephone Calls hourandweekend calls resulting in telephone treatment, may be billed a telephone consultation fee from $ to $ Non Urgent Pharmacy request hourvoicemailbox forourpatientstoleavenon weekdays.