Frood Eelani, DO

Thank you for choosing our office. In order to serve you properly, we need the following information. All information will be confidential.

By typing your name in the signature boxes you are consenting to digital signatures.

Patient Name (Last, First, Middle) * Date of Birth * Social Security Number Gender * Race Cell Phone Number * Home Phone Number Address * City, State * Zip Code * Email Address Marital Status * Referred By Preferred Pharmacy Phone Number & Name Patient Employer Employer Phone Number Insurance Name * Insurance ID Number * Do you have additional insurance? *

Patient's authorization to release medical information and claim payment

Please remember it is your responsibility to pay any deductible amount, co-insurance, copay, or any other balance unpaid by your insurance. In order to control your costs of billing, we request that your copay or coinsurance for each office visit be paid at the time of the visit. If this account was assigned to collections or an attorney, the prevailing party shall be entitled to reasonable attorney's fees and costs of collections. I authorize release of information concerning my or my child(s) health care, advice, and treatment provided for the purpose of evaluations and administering claims of insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to Frood Eelani, DO. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.

Patient Signature * Date of signature *

MEDICATION AGREEMENT

Dear Patient,

It is our office policy that we do NOT prescribe chronic narcotic medications to patients seeking to become established with us. Patients who are on chronic narcotic medications (e.g. hydrocodone, morphine, tramadol, codeine, etc) need to be established with a pain management specialist prior to their first visit with us.

It is also our policy that we do not prescribe chronic benzodiazepines (e.g. xanax, valium, etc), ADHD medications (adderal, etc), or sleep aides (e.g. ambien, restoril, etc) to patients seeking to become established with us. Patients who are on chronic benzodiazepines, ADHD medications, or sleep aides need to be established with a psychiatrist prior to their first visit with us.

Patient Signature * Date of Signature *

CONSENT FOR TREATMENT

I hereby authorize Dr. Frood Eelani to render routine medical care to the patient indicated on this form and to fulfill the orders of the physician: including consultants, associates, and assistants of the physician's choice. The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient will not be provided medical care except in the case of emergency.

Signature of patient or legal guardian * Printed name of patient or legal guardian and relation if applicable * Date of signature *

PATIENT RECORD OF DISCLOSURES

In general, HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means such as sending correspondence to the individual's office instead of the individual's home.

I wish to be contacted in the following manner (fill out all that apply):

Cell Phone * Home Phone Work Phone Written Communications Other people we may speak to regarding your medical information (spouse, child, relative, etc) * CONTACT PREFERENCE * May we leave detailed voice messages? * Patient Signature * Patient DOB * Date of Signature *

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES

I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document if requested.

Signature of patient * Date of signature *

PATIENT HISTORY

Please list your past surgeries * Please list medical conditions that you have been treated for: (ex: high blood pressure, diabetes, thyroid disease, heart disease, headaches, etc) * Please list your allergies * Other Allergies Do any of your blood relatives have or have had: high blood pressure, diabetes, heart attack, thyroid disease, cancer, other (please list relation to you and condition) * Do you now or have you ever consumed alcohol? * If yes, how many per day? Do you now or have you ever used IV drugs? * Do you currently smoke cigarettes? * If yes, how many per day? If yes, how many years have you smoked? If you used to smoke, how many cigarettes did you smoke per day? How many years did you smoke? What year did you quit? Do you experience any of the following? *

MEDICATION LIST

We only do refills Mon-Thur from 830-5 and WILL NOT do them on weekends or on holidays. Please call your pharmacy in advance to avoid running out of your medications.

Please list your medication(s), strength(s), and how many times per day you take it. *

***Dr. Eelani asks that all patients bring ALL pill bottles they are taking with them to each appointment. Failure to do so could result in your appointment being rescheduled.

Please fill in the approximate date the following tests were last performed. Please put NA if it is not applicable to you or has never been done.

Colonoscopy * Eye Exam * Dexascan/Bone Density * Mammogram * Pap Smear * Flu Vaccine * Pneumovax 23 (pneumonia vaccine) * Prevnar 13 (pneumonia vaccine) * Zostavax (shingles vaccine) * Zostrix (shingles vaccine) * Tetanus Vaccine * COVID VACCINE * COVID VACCINE COVID VACCINE COVID VACCINE Name of last primary care doctor seen? * Approximate date last seen * Patient Signature * Date of signature *