Modupe Aiyegbusi, MD - Publicforms

Available Forms

Acute Visit Questionnaire Adult +18 CPE- Physical Forms Adult Health & History Form Adult Vaccine Questionnaire Ages 12-17 CPE - Physical forms Ages 5-8 CPE - Physical forms Ages 9-11 CPE Physical forms Child/Teen Vaccine Questionnaire Consent to use Telemedicine Covid-19 Screening Diabetes Form Flu Vaccine Questionnaire 21-22 Follow-Up Visit Questionnaire GAD 7- Generalized Anxiety Screening Medicare Wellness New Medicare Wellness New patient pediatric Health & History Form Ages 12-17 New patient pediatric Health & History Form Ages 5-8 New Patient Registration form all ages PHQ-9 - Patient Health Questionnaire Pre-Op/ Physical form Tuberculosis Risk Assesment Questionnaire

New Patient Registration form all ages

Patient Name: *

Last Name, First Name, Middle Name

Date of Birth *

Sex *

Primary Spoken Language *

Marital Status: *

Race

Ethnicity

Mailing Address *

City *

State

Zip Code *

Which PHARMACY do you prefer? *

Please provide name and address or phone number, thank you

Preferred Telephone # for routine Communication: *

Home, Cell or Work

Secondary Phone #

Home, Cell or Work

Email:

Emergency Contact (if patient is a child, please provide an emergency contact other than a parent/guardian.)

Contact Name: *

Phone Number# *

Patient Record Disclosure-- (who can we release medical information to)

Name & Relationship *

Insurance Information

Primary Insurance *

Member ID #

Group #

Subcriber:

if other than yourself, provide name and date of birth

Secondary insurance

If applicable

Member ID #

Eligibility Guarantee

I hereby certify that I am eligible with the health insurance company under the subscriber indicated on my registration form. I also certify that I have chosen Dr. Aiyegbusi, Modupe to provide healthcare services. I understand that if the above is not true or I am not eligible under the terms of my medical hospital subscriber agreement, I am liable for any and all charges for services Rendered. Also, if the above is not true, I agree to pay in full for all services rendered within thirty days of receiving a bill.

Authorization for release of medical information and assisngment of benefits

I hereby authorize and request the insurance company(s), or agent thereof, to pay directly to Modupe A. Aiyegbusi and Associates for services provided to me by Dr. Aiyegbusi, Modupe. I am aware that I am financially responsible for charges not covered by this assignment. I authorize refund or overpaid insurance benefits where my coverage are subject to coordination of benefits. This signature will also serve as an authorization to release medical information necessary to satisfy payment.

Office Policy for Narcotic Prescriptions

1. Please be aware that narcotics will only be prescribed during office hours. (There will be no refills after hours or weekends.)

2. Narcotics need to be obtained from only one physician. If you obtain narcotics from ANY other physician, I will terminate the narcotic prescription from my office permanently.

3. I do not replace lost of misplaced narcotic medications NOR will I refill your medication if you over use it, before next refill is due.

4. If you fail to follow through with the specialist referral or plan of action for treatment to relieve your pain, I will not continue narcotic medication.

YOU WILL NEED REVIEW OF YOUR NEED FOR NARCOTIC MEDICATION EVERY MONTH.

Name *

Electronic Signature

Date

* Required field