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ENDOCRINOLOGY MEDICAL GROUP OF ORANGE COUNTY, INC.
725 W. La Veta Avenue, Suite 220 Orange, CA 92868
PATIENT REGISTRATION FORM NAME (LAST, FIRST INIT.)
ADDRESS CITY STATE ZIP CODE
HOME PHONE NO. CELL PHONE NO. EMAIL DATE OF BIRTH
SOCIAL SECURITY NO. SEX (M / F) MARITAL STATUS
OCCUPATION EMPLOYER
EMPLOYER ADDRESS CITY STATE ZIP CODE
EMPLOYER PHONE NO. REFERRING PHYSICIAN EMPLOYER ADDRESS
PRIMARY INSURANCE INSURANCE NAME & ADDRESS IN CASE OF EMERGENCY CONTACT PERSON
SUBSCRIBER NO. GROUP NO.
RELATIONSHIP PHONE NO.
INSURED’S NAME INSURED’S PHONE NO. INSURED’S PHONE NO.
INSURED’S SOCIAL SECURITY NO.
INSURED’S EMPLOYER
EMPLOYERS ADDRESS CITY STATE ZIP CODE
SECONDARY INSURANCE INSURANCE NAME & ADDRESS
SUBSCRIBER NO. GROUP NO.
INSURED’S NAME INSURED’S DATE OF BIRTH
INSURED’S PHONE NO. INSURED’S SOCIAL SECURITY NO.
INSURED’S EMPLOYER
EMPLOYERS ADDRESS CITY STATE ZIP CODE
HOW DID YOU HEAR ABOUT US?
INSURANCE:____________________________
FAMILY MEMBER:_______________________
YELP.COM
HEALTHGRADES.COM
DOCTOR:________________________
FRIEND:_________________________
OTEHR:________________________
I authorize payment of medical benefits be made directly to the physician provider for services rendered.
DATE SIGNED (Insured or Authorized)
I authorize any insurance company, organization, employer, hospital, physician, or pharmacist to release any information to this claim and the
expenses reported.
DATE SIGNED (Insured or Authorized)
ENDOCRINOLOGY MEDICAL GROUP OF O.C., INC
725 W LA VETA AVENUE #220
ORANGE, CA 92868
714-771-5700
PATIENT HISTORY
DATE: ______________
NAME: ____________________________________________AGE____BIRTHDATE_______________
OCCUPATION: ________________________________ REFERRED BY__________________________
REASON FOR VISIT__________________________________________________________
MEDICATION AND DOSAGES: ALLERGIES:
_____________________ __________________ __________________ _____________
_____________________ __________________ __________________ _____________
_____________________ __________________ __________________ _____________
_____________________ __________________ __________________ _____________
_____________________ __________________ __________________ _____________
IMMUNIZATIONS AND DATES:
Tetanus_______ Flu Shot________ Pneumonia Vaccine ________TB Skin test ________Hepatitis______
SOCIAL HISTORY:
Birthplace_______________________________Education_______________________________
Ever smoked? _______Do you still smoke? _____ How many packs per day? _________
Alcoholic Beverages? _____________ Coffee/Tea/Soda? ______ How many cups per day? _________
SURGERIES AND DATES
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
HOSPITALIZATIONS AND DATES
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
DOCTORS SEEN IN THE PAST TWO YEARS AND REASON FOR VISIT
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
3. ____________________________________________________________________________________
4. ____________________________________________________________________________________
PAST MEDICAL HISTORY
Diabetes_______ Hepatitis_______ Hypertension_____ Stroke ______ Cancer ______ Thyroid ______
Anemia________ Asthma_______
Transfusions __________ Pregnancy___________
PATIENT SIGNATURE______________________
Page 1 of 2 Consent Form
ENDOCRINOLOGY GROUP OF ORANGE COUNTY, INC.
725 W. La Veta Ave., Suite 220
Orange, CA 92868
CONSENT FORM
Patient: ________________________________________ Date: _______________
In connection with the medical services that I am receiving, I hereby authorize Drs. Rettinger,
Dr. Shah, Dr. Rockoff, their respective agents, and staff to disclose any and all information
concerning my medical condition and treatment (including, but not limited to, super-
confidential information concerning sexually transmitted diseases, mental health, chemical
dependence, or other such information), including copies of applicable hospital and medical
records, to:
A. Any third party payer covering the medical services of the patient;
B. Other health care professional and institutions involved in the delivery of health care to
the patient;
C. The proponent of any legally sufficient subpoena, or in response to a court order;
D. Employees and agents of the practice, to the degree necessary to facilitate the provision
of health care services and payment for such services;
E. Pharmacies; and
F. As otherwise required by law.
When providing information to me, information may be transmitted by any and all of the
following means (initial all that apply):
________ Telephone messages on an answering machine or voicemail
________ Messages to the following family members or friends:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Page 2 of 2 Consent Form
In each case, the practice shall take reasonable steps to ensure that only the minimum
necessary information is disclosed in accordance with the above. I further understand that I
have been given access to the physician’s privacy notice and that I have had the opportunity to
place special instructions upon the consent hereby given:
Special Instructions:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I understand that regardless of my insurance coverage, I am ultimately responsible for
payments on my account with Endocrinology Medical Group of O.C., Inc. All co-pays and
deductibles are to be paid at the time of service. If I have no insurance coverage, payment is
required at the time of service. Should there be any problem in collecting from my insurance
company, I understand that I am responsible to call my insurance company and resolve the
matter promptly. Should the insurance check be sent to me in error, I understand that I am to
remit it to Endocrinology Medical Group of O.C., Inc. and any balance so remaining. Should my
claim for coverage be denied for any reason, I understand that I am responsible for payment in
full to Endocrinology Medical Group of O.C., Inc. I am responsible to inform them of any change
in my insurance coverage as well.
This consent is valid from the date executed until revoked in writing by the patient.
Signed: ________________________________________________
Date: ________________________
Witness: _______________________________________________
ENDOCRINOLOGY GROUP OF ORANGE COUNTY, INC.
FINANCIAL AND APPOINTMENT POLICIES
Thank you for trusting your Endocrine needs to Endocrinology Group of Orange County, Inc. We
strive to provide excellent medical care to all of our patients. Informing you in advance of our
office policies allows for better communication between our patients and office. If you have any
questions, please do not hesitate to ask a member of our staff.
1. According to your insurance plan, you are responsible for any and all co-payments, co-
insurance and deductible payments. These amounts are not negotiable and will be
collected at the time of service. If you are a cash patient, full payment is due at the time
of service (no exceptions).
2. As a courtesy, we verify your insurance prior to your visit. This is not a guarantee of your
eligibility. It is your responsibility to understand your benefit plan. It is your
responsibility to know if a prior authorization is needed for a procedure and what
services will be covered. We will assist with this process; but we are not responsible for
the ultimate payment determination by your insurance carrier.
3. You agree to pay all cost of collection including reasonable attorney fees and court costs
should you fail to pay the amount owed when due.
4. We require 24 hours’ notice for cancelling appointments. If you fail to notify us per this
policy, you will be charged a $30.00 fee which is payable prior to rescheduling.
5. In order for our office to run as efficiently as possible, we ask that all patients be on time
for their appointments. Patients that arrive more than 10 minutes late may be asked to
reschedule to an open appointment slot for the same day. If there is no open
appointment time slots for the same day, the patient may be asked to reschedule to
another day.
6. A $20.00 fee is charged for all NSF checks in addition to any bank fees incurred.
7. We charge a $50.00 fee to fill out forms. The payment is due in advance and we require
up to 5 business days for completion.
I have read and understand the Financial and Appointment Policies and agree to comply and
accept responsibility for any payment that becomes due as outlined above.
_____________________________________
Patient Name
_____________________________________
Responsible Party Name Relationship
_____________________________________
Responsible Party Signature Date
Endocrinology Medical Group of Orange County
Cancellation Policies
1. Cancellation
If you need to change or cancel an appointment, please call to cancel at
least 24 hours prior to your scheduled appointment time. This will allow us
to fill your appointment with another patient who needs our care. Failure
to cancel 24 hours in advance will result in a cancellation fee of $30.
2. Failure To Come To A Scheduled Appointment
Here at E.M.G.O.C., we strive for excellence in patient care. When you are
scheduled for an appointment, we prepare for your visit. Failure to come to
a scheduled appointment will result in a $30 fee. Please call to cancel at
least 24 hours prior to your scheduled appointment time.
Patient Name (please print): ____________________________
Patient Signature: _____________________________________ Date: _____________
NAME: _________________________________________ DATE: __________________
ETHNICITY:
o AMERICAN INDIAN o AFRICAN AMERICAN o NATIVE HAWAIIAN o ASIAN
o HISPANIC/ LATINO o WHITE o REFUSE
LANGUAGE PREFERENCE:
o ENGLISH o SPANISH o CHINESE o FRENCH o GERMAN o ITALIAN
o JAPANESE o KOREAN o PORTUGUESE o RUSSIAN o OTHER ___________________
TOBACCO USE:
HAVE YOU EVER SMOKED? YES NO CURRENT SMOKER? YES NO IF SO, FOR HOW MANY YEARS? ___________ HOW MANY PACKS DAILY? __________ FORMER SMOKER: HOW MANY YEARS AGO DID YOU QUIT? _____________
PHARMACY PREFERENCE:
______________________________________________________________________________
(NAME ADDRESS CITY ZIP CODE)
MEDICATION LIST (PLEASE INCLUDE SUPPLEMENTS AND OTCS) OR PLEASE ATTACH YOUR OWN MEDICATION LIST.
MEDICATION NAME STRENGTH DOSE FREQUENCY
ALLERGIES: ____________________________________________________________________
LAB FACILITY NAME: DATE OF LAST LAB:______________ __
RADIOLOGY (ULTRASOUND/ X-RAY/ SCANS): LOCATION: _ DATE OF MOST RECENT:________ ____