3

merged - sa1s3.patientpop.com · Payment Methods and Consent for Services Please choose a method of payment below: PAYMENT IN FULL: Payment in full at time of service, this office

Download PDF Report

Upload
others
View
3
Download
0

Embed Size (px)

Citation preview

Page 1: merged - sa1s3.patientpop.com · Payment Methods and Consent for Services Please choose a method of payment below: PAYMENT IN FULL: Payment in full at time of service, this office

Page 2: merged - sa1s3.patientpop.com · Payment Methods and Consent for Services Please choose a method of payment below: PAYMENT IN FULL: Payment in full at time of service, this office

Page 3: merged - sa1s3.patientpop.com · Payment Methods and Consent for Services Please choose a method of payment below: PAYMENT IN FULL: Payment in full at time of service, this office

sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt

sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt

Documents

sa1s3.patientpop.com · Web viewCancer (what area of body? Migraines Anesthesia Problems COPD (lung disease) Hepatitis Reflux (GERD) Asthma Diabetes High …

sa1s3.patientpop.com · Web viewCancer (what area of body? Migraines Anesthesia Problems COPD (lung disease) Hepatitis Reflux (GERD) Asthma Diabetes High …

Documents

sa1s3.patientpop.com · Resective osseous surgery has been performed for many years. G. V. Black mentioned the reshaping of a shallow interproximal crater in 1866, and resective osseous

sa1s3.patientpop.com · Resective osseous surgery has been performed for many years. G. V. Black mentioned the reshaping of a shallow interproximal crater in 1866, and resective osseous

Documents

THE METROPOLITAN NEROSURGERY GROUP PATIENT …sa1s3.patientpop.com/assets/docs/164011.pdfPLEASE LIST ANY CONSERVATIVE TREATMENTS THAT YOU HAVE TRIED SINCE LAST VISIT: PHYSICAL THERAPY:

THE METROPOLITAN NEROSURGERY GROUP PATIENT …sa1s3.patientpop.com/assets/docs/164011.pdfPLEASE LIST ANY CONSERVATIVE TREATMENTS THAT YOU HAVE TRIED SINCE LAST VISIT: PHYSICAL THERAPY:

Documents

Untitled-2 [sa1s3.patientpop.com]Untitled-2 Author: Alex Fedoryanskyy Created Date: 11/9/2019 12:34:26 PM

Untitled-2 [sa1s3.patientpop.com]Untitled-2 Author: Alex Fedoryanskyy Created Date: 11/9/2019 12:34:26 PM

Documents

sa1s3.patientpop.com Screening/ Teratology Counseling; Family History; on.com Schedule visits with my Doctor for routine physical exams and other recommended health screeningst

sa1s3.patientpop.com Screening/ Teratology Counseling; Family History; on.com Schedule visits with my Doctor for routine physical exams and other recommended health screeningst

Documents

cv resume - sa1s3.patientpop.com · Title: cv resume.pdf Author: rmorales Created Date: 6/24/2019 9:04:39 AM

cv resume - sa1s3.patientpop.com · Title: cv resume.pdf Author: rmorales Created Date: 6/24/2019 9:04:39 AM

Documents

Full page photo - sa1s3.patientpop.com · Title: Full page photo Author: rgrice Created Date: 9/12/2014 1:20:28 PM

Full page photo - sa1s3.patientpop.com · Title: Full page photo Author: rgrice Created Date: 9/12/2014 1:20:28 PM

Documents

sa1s3.patientpop.com · 2020. 10. 7. · Famlly and Friends — ... We will continue to protect your private health Informatlon as required by law. ... have prov ded, including contact

sa1s3.patientpop.com · 2020. 10. 7. · Famlly and Friends — ... We will continue to protect your private health Informatlon as required by law. ... have prov ded, including contact

Documents

sa1s3.patientpop.com · chronic lung disease kidney infection/ stones tuberculosis venereal disease heart conditions/ murmur diabetes high blood pressure stroke deep vein thrombosis

sa1s3.patientpop.com · chronic lung disease kidney infection/ stones tuberculosis venereal disease heart conditions/ murmur diabetes high blood pressure stroke deep vein thrombosis

Documents

sa1s3.patientpop.com · US ENSURE THE QUALITY OF YOUR CARE EXCELLENT. WE LOOK FORWARD TO WORKING WITH YOU Name :( Last, First, Ml Patient Information ... orthodontic treatment If

sa1s3.patientpop.com · US ENSURE THE QUALITY OF YOUR CARE EXCELLENT. WE LOOK FORWARD TO WORKING WITH YOU Name :( Last, First, Ml Patient Information ... orthodontic treatment If

Documents

sa1s3.patientpop.com · 2018. 12. 14. · • POMCO • Screen Actors Guild • UnitedHealthcare • UnitedHealthcare International Dr. Michael Y. Mizhiritsky, MD Participates: •

sa1s3.patientpop.com · 2018. 12. 14. · • POMCO • Screen Actors Guild • UnitedHealthcare • UnitedHealthcare International Dr. Michael Y. Mizhiritsky, MD Participates: •

Documents

sa1s3.patientpop.com · RonaCdS. {ManaCo, {M.D. Medical Information Communication Preferences Date of Birth: Patient Name: The HIPAA privacy rule was created to give individuals the

sa1s3.patientpop.com · RonaCdS. {ManaCo, {M.D. Medical Information Communication Preferences Date of Birth: Patient Name: The HIPAA privacy rule was created to give individuals the

Documents

AFFORDABLE HEALTHCARE SERVICES TWO CONVENIENT …sa1s3.patientpop.com/assets/docs/21083.pdfg LOS ANGELES Mary B. Henry Community Clinic 10901 South Vermont Avenue Los Angeles, CA 90044

AFFORDABLE HEALTHCARE SERVICES TWO CONVENIENT …sa1s3.patientpop.com/assets/docs/21083.pdfg LOS ANGELES Mary B. Henry Community Clinic 10901 South Vermont Avenue Los Angeles, CA 90044

Documents

sa1s3.patientpop.com · 2018-02-22 · unpleasant side effect of these natural changes is constipation. Increasing fiber (Fruits, vegetables, whole grains, beans, and legumes), water

sa1s3.patientpop.com · 2018-02-22 · unpleasant side effect of these natural changes is constipation. Increasing fiber (Fruits, vegetables, whole grains, beans, and legumes), water

Documents

sa1s3.patientpop.com · This article summarizes the clinical trial ... The benefits measured on the visual analogue scale and Hospital Anxiety and Depression Scale persisted through

sa1s3.patientpop.com · This article summarizes the clinical trial ... The benefits measured on the visual analogue scale and Hospital Anxiety and Depression Scale persisted through

Documents

ECTOPIC PREGNANCY - sa1s3.patientpop.com · Causes Women with pre-existing tubal damage are more likely to develop an ectopic pregnancy. In fact, 50 percent of ectopic pregnancies

ECTOPIC PREGNANCY - sa1s3.patientpop.com · Causes Women with pre-existing tubal damage are more likely to develop an ectopic pregnancy. In fact, 50 percent of ectopic pregnancies

Documents

sa1s3.patientpop.com · 2020. 8. 18. · Wound debridement is essential in treat- ing chronic VSUs. Removing necrotic tissue and bacterial burden through debridement enhances wound

sa1s3.patientpop.com · 2020. 8. 18. · Wound debridement is essential in treat- ing chronic VSUs. Removing necrotic tissue and bacterial burden through debridement enhances wound

Documents

sa1s3.patientpop.com · If you are taking any over-the-counter herbal/alternative medications ... o Shower shampoo your hair within 24 hours of ... For anesthesia related questions

sa1s3.patientpop.com · If you are taking any over-the-counter herbal/alternative medications ... o Shower shampoo your hair within 24 hours of ... For anesthesia related questions

Documents

Laser Therapy - sa1s3.patientpop.com · MLS Laser Therapy is painless. Most patients report no sensation at all while receiving laser therapy. Treatments average 8 minutes. MLS Laser

Laser Therapy - sa1s3.patientpop.com · MLS Laser Therapy is painless. Most patients report no sensation at all while receiving laser therapy. Treatments average 8 minutes. MLS Laser

Documents

sa1s3.patientpop.com · remember to bring with you any insurance cards and communication from a referring doctor. Please plan to arrive 15 minutes prior to your scheduled appointment

sa1s3.patientpop.com · remember to bring with you any insurance cards and communication from a referring doctor. Please plan to arrive 15 minutes prior to your scheduled appointment

Documents

sa1s3.patientpop.com · health and keeping your scheduled appointments allows us to be partners in your dental care.Your appointment is a reservation.We truly appreciate your courtesy

sa1s3.patientpop.com · health and keeping your scheduled appointments allows us to be partners in your dental care.Your appointment is a reservation.We truly appreciate your courtesy

Documents

sa1s3.patientpop.com · Web viewI authorize this practice to submit a claim and, if needed, medical documentation to my insurance company, attorney or other financially responsible

sa1s3.patientpop.com · Web viewI authorize this practice to submit a claim and, if needed, medical documentation to my insurance company, attorney or other financially responsible

Documents

HEALTH HISTORY REGISTRATION - sa1s3.patientpop.com · PERIO: ORTHO: ENDO: , ORAL SURG: MD: OTHER: _ NOTES CONSENT The undersigned hereby authorizes the Doctor to take X-rays, study

HEALTH HISTORY REGISTRATION - sa1s3.patientpop.com · PERIO: ORTHO: ENDO: , ORAL SURG: MD: OTHER: _ NOTES CONSENT The undersigned hereby authorizes the Doctor to take X-rays, study

Documents

sa1s3.patientpop.com · history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves

sa1s3.patientpop.com · history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves

Documents

sa1s3.patientpop.com · and constipation — IBS, gluten intolerance, celiac disease, heartburn/acid reflux/GERD and ulcers (peptic ulcers and stomach ulcers), to name a few. A variety

sa1s3.patientpop.com · and constipation — IBS, gluten intolerance, celiac disease, heartburn/acid reflux/GERD and ulcers (peptic ulcers and stomach ulcers), to name a few. A variety

Documents

da Vinci Si Surgical System - sa1s3.patientpop.com mm Semi-Rigid Instruments • Designed with the flexibility to go through curved ... is designed to limit cannula movement at the

da Vinci Si Surgical System - sa1s3.patientpop.com mm Semi-Rigid Instruments • Designed with the flexibility to go through curved ... is designed to limit cannula movement at the

Documents

sa1s3.patientpop.com · PETRIN DERMATOLOGY CLINIC POLICIES l, the undersigned, hereby authorize Petrin Dermatology to receive the benefits to which l, or my dependents are …

sa1s3.patientpop.com · PETRIN DERMATOLOGY CLINIC POLICIES l, the undersigned, hereby authorize Petrin Dermatology to receive the benefits to which l, or my dependents are …

Documents

John B. Monaco, MD, FACOG, FAARFM, ABAARM Nashville ...sa1s3.patientpop.com/assets/docs/65486.pdfmodifications. The cornerstone of wellness and lifestyle is nutrition. Part of your

John B. Monaco, MD, FACOG, FAARFM, ABAARM Nashville ...sa1s3.patientpop.com/assets/docs/65486.pdfmodifications. The cornerstone of wellness and lifestyle is nutrition. Part of your

Documents

sa1s3.patientpop.com · Asthma [2 Emphysema Bronchitis HIV+ Cl Eating Disorder Other: Frequency Arthritis Diabetes: Cl Diet Controlled Pill Controlled C] Insulin Controlled High Blood

sa1s3.patientpop.com · Asthma [2 Emphysema Bronchitis HIV+ Cl Eating Disorder Other: Frequency Arthritis Diabetes: Cl Diet Controlled Pill Controlled C] Insulin Controlled High Blood

Documents