John R Knudsen MD

Home Forms

Available Forms

Insurance Information (new patient or change of insurance) New Patient Information Patient Medical History - New patients Prescription Refill Request Privacy Practices Questionnaire Depression Screening - optional Records Release from previous provider to Dr. Knudsen Telehealth Consent

New Patient Information

Personal Information

Name *

Date of Birth *

Social Security Number

Address *

City *

State *

Zip Code *

Mobile Phone

Home Phone

Do we have permission to leave a detailed message with lab and x-ray results?

Yes

Email Address

Preferred form of contact (you may select more than one)

Phone

Email/portal

Employer

Occupation or former occupation

Marital Status

Single

Married

Divorced

Widowed

Spouse/Partner Name

May we contact your spouse/partner if we cannot reach you?

Yes

Medical History

Current Medications

Allergies

Medical Conditions/Illnesses

Surgeries or Hospitalizations

Do you smoke?

Yes

Do you drink?

Yes

If so, how much and how often?

Family History

Additional Information

Please share any additional information you would like us to know

Authorization and Release

I hereby authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for all charges whether or not paid by insurance. I also authorize the physician to release all information, regardless of nature, that may be required in the processing of my claim. I authorize the use of this signature on all my insurance submissions.

Acknowledgement of Privacy Practices

We keep a record of the health care services we provide to you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your records to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our office at 360-483-5260.

Printed name *

Date signed *

I accept *

By selecting the "I Accept" box, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement.

* Required field

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