PATIENT INFORMATION (PLEASE PRINT) Please …

1 George B. Blake, , PATIENT INFORMATION ( Please print ) Please read and complete the form in its entirety. Last Name: Date of Birth: First Name: MI: Sex: Marital Status: Address Line 1: E-mail: Address Line 2: Social Security: City: Employers Name: State: Zip: Work Number: Home#: Cell#: Primary Care Dr. Race: Language of choice: Referring Doctor: Ethnicity: Hispanic / Latino D Other: D Decline to report: D PHARMACY INFORMATION Pharm#2 Name:Preferred Pharma 's #1 Name: Location:Pharmac location: (Statements will be addressed to the responsible party) Responsible Party Name: Emergency Contact Name: Address: Address: Phone: Phone: Relationship: Relationship: INSURANCE INFORMATION PRIMARY INSURANCE: I PHONE# CLAIMS ADDRESS: GROUP#POLICY# BIRTH DATE: POLICY HOLDER NAME: SECONDARY INSURANCE: I PHONE# CLAIMS ADDRESS: GROUP#POLICY# BIRTHDATE:POLICY HOLDER NAtvIE.

2 RELEASE AND ASSIGNMENT I authorize release of any INFORMATION necessary to process my insurance claims and assign payment directly to Dr. Blake. I understand I am responsible for any uncovered fees. I grant permission to view my prescription history from external sources. I acknowledge receipt of notice of Dr. Blake's privacy practices. Responsible Party's Signature: _____ Date____ Please print Name: __-----'-_____ PATIENT Name: _____ DOB: __I __ I___ Date: __ 1__1___ Briefly describe the reason for today's visit: _____ Severity: Mild 0 I Moderate 0 ISevere 0 Duration: _____ Male:D I Female:D Height __ weight: ___ MEDICAL HISTORY ALLERGIES Circle all that apply to you.

3 ALLERGIES TO MEDICATIONS: REACTION: Heart: High BP, Stroke, TIA 0 I have NO allergies to medications Pulmonary (Lung): Asthma, COPD, Emphysema Hepatitis: -A, B or C Thyroid Problems Diabetes - Type I or Type II SOCIAL INFORMATION AND HABITS Sleep Apnea 00 you currently smoke? Yes No HIV / AIDS How much per day? How many years? Reflux (GERD) If you quit smoking when? Cancer (Indicate site and type) How much did you smoke? How many years? 00 you drink alcohol? No Yes Other not listed If YES howmuch? 0 Check here if NO Items above apply to you SURGICAL HISTORY FAMILY HISTORY Circle all that apply to you Has any family member had any of the Which Family following Member Ear Surgery Heart attack Tonsils Heart stents Adenoid High blood pressure Deviated Nasal Septum Asthma Sinus Surgery Emphysema or COPO Thyroid Surgery Thyroid problems Vocal Cord Surgery Diabetes Tracheotomy Sleep apnea Heart: Bypass, heart valve, carotid artery Parkinson's.

4 Tremor Pacemaker Bleeding disorder Cancer (Site and type) Other not listed HAVE YOU BEEN PREVIOUSLY HOSPITALIZED If YES Please explain: o Check here if NO items above apply to you George B. Blake, , 60S S Fremont Ave, Suite A TURN THE PAGE OVER TO FILL OUT THE BACK ALSO .. Tampa, Florida 33606 ~ith and how often you take each one. Sleep problems? loss or other on or Mouth pain, ulcers, or sore throat? Hoarseness? Heartburn or acid taste in mouth or throat? Swallowing problems? Persistent cough? Wheezing? of breath? other abdominal symptoms? Immune system or swollen nodes? Fainting spells, weakness of arms or legs, seizures or other neurological symptoms?

5 MEDICATIONS, REVIEW OF SYSTEMS PATIENT ._____ DOB:: __1_ ___ Date: that you take, Have you HAD any problems with:(Include non~prescription medicines.) I DO NOT use any regularly REVIEW OF Do YOU currently HAVE any problems with: Weight gain or loss7 If YES to any Items in either column, Please describe: B. Blake, , 605 S Fremont Ave, Suite A Florida 33606 George B. Blake, , 605 S Fremont Ave, Suite A Tampa, Florida 33606 Office (813) 251-0209 Fax (813) 25S-D600 PERMISSION FOR TREATMENT I, the undersigned, hereby voluntarify consent to medical care/diagnostic treatment and or minor surgical treatment by Dr. George Blake deemed advisable and necessary in the diagnosis and treatment of mv condition.

6 I am aware that the" practice of medicine is not an exact science and I acknowledge that no guarantees have been .. made to me as a result of treatment or examination in the office. I authorize the release ofany of my past/current medical records that are needed for my treatment from any prior healthcare providers. Date: _____ HIPAA PRIVACY POLICY ACKNOWLEDGE STATEMENT I have bee"n informed that Dr. Georle Blake has a privacy policy in place according to the health Insurance Portability and Accountability Act of 1996 (HIPPA). As a PATIENT Of' parent I guardian ofa PATIENT of Dr. George Blake Iunderstand the following: 1. Dr.

7 George Blake has a privacy policy in effect in our office. 2. Dr. Georle Blake has made this polley readily available to me. 3. Dr. Geo,..e Blake has made me aware that I am entitled to a copy of this privacy policy if I a copy for my own personal records. After reading the statements Please atthe bottom of this sheet, acknowledging that you have been advised of the privacy policy implemented by Dr. Georle Brake and have read and understand the acknowledgment form. Ifyou would like a copy of the privacy policy Please asked for one at the front desk or print it from our website No, I do not want a copy ofthe policy, but I do acknowledge.

8 That it exists. __ Yes, I have requested and been given a copy of the privacy policy. Date: _____ DESIGNATED RELATIVE I Authorize Decision and Release of My General Medlcar Condition andD;agnosis (including treatment, payment and health care operations) with: ( ) Spouse ( ) Children ( ) list the family members if any, We Mav Inform about Your Medical Condition, and/or in Case of an ~_____Relationship: _____Phone Number: _____ .._____Relationship: Phone Number~_____ ..'''.5' .. May Be Left on My Answering Machine Regarding My Health & Appointments Made: DYes DNo print Name: _____ Date: _____ .,&.!1rBayCa e Healt h System Electronic Medical Records Consent to Share My Health INFORMATION With the BayCare Electronic Health Exchange.

9 The BayCare Electronic Health Exchange (BayCare eHX) is an excit ing program designed to improve your health care and make office visi ts easier and more convenient. This authorization will allow all of your doctors partici pating in the BayCare eHX t o enroll you in the BayCare eHX and t o disclose your demographic, insurance and medical INFORMATION (collectively, your "health INFORMATION ") to the BayCare eHX so that it can be shared with other providers of health care, including doctors, nurses, health professionals, hospitals and other health care facilities. Only health care providers and authorized personnel that participate in the BayCare eHX, and others whose job it is to maintain, secure, monitor and evaluate the operation of the BayCare eHX, will be able to access your health INFORMATION .

10 The BayCare eHX will allow your providers access to your health INFORMATION more quickly and accurately than with paper charts. You may use this Consent Form to decide whether or not to allow the BayCare eHX to see and obtain access to your health INFORMATION in this way. You can give consent or deny consent, and this form may be filled out now or at a later date. Your choice will not affect your ability to get medical care or health insurance coverage. Your choice to give or to deny consent may not be the basis for denial of health services. However, to the extent you have denied consent, you understand t hat your health INFORMATION will not be available to other providers on the BayCare eHX for your medical treatment.