CARY ADULT MEDICINE - Publicforms

Available Forms

Back Pain E-Visit Billing Question Blood Pressure Log Blood Sugar Readings Cold/Flu/Sinus/Cough//Throat/Respiratory Infection Comments or Suggestions Conjunctivitis/Pink Eye Depression Screening (PHQ9) Flu Shot Health Care Question HIPPA Hospitalization Insurance Change Form Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam New Patient Medical History New Patient Registration Form On Demand Appointment Registration Password - Patient Request for Secure Password Patient Education Classes Prescription Refill Request Preventative Care Referral Question Specialist/ER/Hospital/Testing Update Specialist/Urgent Care or Hospital Visits Survey- Cary Adult Medicine Telemed Urinary Tract Infection Voluntary Alignment for Medicare ACO REACH Yeast Infection

New Patient Registration Form

Todays Date *

First Name *

Middle Name *

Last Name *

Street Address 1 *

Street Address 2

City *

Zip Code *

Email Address *

Sex *

Date of Birth *

Home Phone # *

Cell Phone #

Marital Status *

Employment Status

Employer

How did you hear about us?

Relationship to Insured *

Primary Insurance *

Insurance Address Back of Card

Insurance Address 2

Insurance City, State Zip

Insurance Phone Number

Policy Number

Insurance Group #

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationshp

Emergency Contact Cell Phone

Emergency Contact Other Phone

If the patient is not the responsible party for the insurance or insurance is through spouse please complete the following . Otherwise please skip to the end of the form and read disclosure and submit.

Responsible Party

Date of Birth of Responsible Party

Responsible Party First Name

Responsible Party Last Name

Responsible Party Address

Responsible Party City, State Zip

Responsible Party Employer

Responsible Party Phone #

Responsible Party Alternate Phone #

Consent for Treatment : By Submitting this form you hereby consent to examination and treatment by the physician/medical provider and the performance of any procedure that is deemed necessary. You here by authorize payment directly to this medical office from your medical benefits. You also acknowledge that you are responsible for any deductibles, co-pays or other payments for non-covered services. . You authorize Cary Adult Medicine to release Medical Information acquired in the course of your treatment necessary to process insurance claims

I hereby agree to the above statement *

After hitting submit , please go back to the forms tab on this page and scroll down and complete NEW PATIENT MEDICAL HISTORY

* Required field