Patient Intake Form

Step 1 of 14

Patient Information

Patient First Name

Patient Middle Initial

Patient Last Name

Patient D.O.B

Patient Gender

Patient Phone Number

Patient Alternate Phone

Patient Email

Patient Emergency Contact And Relationship

Patient Emergency Contact And Phone Number

By completing this portion of this form, you agree to receive automated phone and/ or text messages that will be made on behalf of our office to remind you of any and all future appointments. Standard text message rates may apply. Your email will be used to send out periodic newsletters and to keep you informed of updates going on within our office.

Primary Care Information

Primary Care Physician Name

Primary Care Physician Phone Number

Primary Care Physician Address

Street Address City State

Pharmacy Information

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

Street Address City State

Insurance Information

Has there been any changes to your insurance since your referring physician sent over your information?

Yes

Briefly describe the changes to your insurance

Regardless of your answer to the above question, please have your insurance card and photo ID with you at the time of your appointment.

Receipt of Notice of Privacy Practices & Patient Consent

Receipt of Notice· of Privacy Practices & Patient Consent for Use and Disclosure of Protected Health Information(Required)

I agree to the Receipt of Notice· of Privacy Practices & Patient Consent

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPP A) I have certain Patient Rights regarding my protected health information. I understand that Arthritis Autoimmune & Allergy, LLC may use and/or disclose my protected health information for treatment, payment or health care operations, which means for providing healthcare to me, the patient, handling billing and payment, and taking care of other health care operations. Unless required by law, there will be no other uses and disclosure of this information without my authorization. Arthritis, Autoimmune & Allergy, LLC has a detailed document called the "Notice of Privacy Practices." It contains a more complete description of my rights to privacy and how they may use and disclose my protected health information. The information is located at the front office and can be made accessible to me upon request,)(•. I understand that I have the right to read the full "Notice of Privacy Practices" document before signing this agreement. If I ask, Arthritis Autoimmune & Allergy LLC, will provide me with the most current "Notice of Privacy Practices." My signature below indicated that I have been given the opportunity to review such copy of the "Notice of Privacy Practices." My signature means that I agree to allow Arthritis Autoimmune & Allergy, LLC to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Arthritis, Autoimmune & Allergy, LLC has taken action relying on this consent.

Signature - Receipt of Notice(Required)

Date - Receipt of Notice(Required)

MM slash DD slash YYYY

Receipt of Notice

Relationship to Patient if signed by other party:

*You may obtain a copy of our "Notice of Privacy Practices" including any revisions of our notice at any time by contacting our office: 1893 N Clyde Morris Blvd, Suite 110 Daytona Beach, FL 32117 (386) 676 - 0307

Office & Financial Policies

I agree to the Office & Financial Policies

1. All co-payments are due at the time of service. It is your responsibility as a patient, to be familiar with your individual insurance benefits prior to service. Please remember to have your insurance card with you at each appointment. 2. Your appointment time is reserved exclusively for you, if you are more than 15 minutes late to your appointment, we will need to reschedule the appointment. Please help us to serve you better by being on time for your scheduled appointments. 3. Effective August 1, 2021, there is a · 40 fee for new patient appointments that are not canceled or rescheduled within 48 hours or if the patient does not show up for the appointment. The fee for established patients will be $25 for appointments not cancelled or rescheduled within 48 hours or if the patient does not show up for the appointment. We accept Visa, MasterCard, American Express and Discover as well as cash and personal check (There will be a $25.00 fee for returned checks). a. Cancellations: If you need to cancel your appointment, please notify our office 48 hours prior to your scheduled appointment. We understand emergencies happen but please be mindful of our other patients that want and need to be seen. b. No Shows: A no show is defined as not showing up for the appointment whether you confirm the appointment or not. We understand emergencies happen but it would be appreciated to notify our office if you are unable to make your scheduled appointment time. c. There will be no action taken for first offenses with established patients. 4. Lab, X-rays and all diagnostic test results are NOT given over the phone but rather at your next visit. If there is an abnormal result that warrants immediate attention, the office will contact you. 5. Please advise our office staff if there are any changes to your phone number, address, email or insurance so all communications with you as a patient are easily made. a. Failure to provide updated insurance information in a timely manner may cause insurance denials and non-coverage for procedures including in-office infusion therapy. Any claims denied due to the lack of updated insurance information will then become the responsibility of the patient. If new insurance information is provided, we will file the claim under that plan if the effective date falls within the range of the date of service. If the claim is denied by the health insurance plan for timely filing, the patient will be responsible for payment of the claim. 6. This practice participates in filling out FLMA and disability claim forms; this includes short-term disability claim forms. Patients are required to be seen for an office visit to have these forms filled out and are required to pay a $25 fee. A co-pay for the appointment may also be required. 7. If you are to request products or documents, be sent via mail, you may be held responsible to pay the allotted shipping cost for the item. Otherwise, products or documents may be picked up at our office at your convenience at no cost. 8. If your account becomes past due, it is your responsibility to clear the debt in full before you may schedule future visits with our office or render any services. By signing below, you acknowledge you have read the above policies and agree to abide by its terms. You also authorize payment directly to the physician of the medical benefits, if any, otherwise payable to you for his/her services as described, realizing you are responsible to pay for non-covered services.

Patient Signature - Office & Financial Policies(Required)

Date -Office & Financial Policies

MM slash DD slash YYYY

Authorization for Release of Medical Information

I Agree

I, hereby authorize the physicians at Arthritis, Autoimmune and Allergy, LLC to release any information acquired in the process of insurance claims. I, also, authorize this office to release my medical records to my primary care and referring physician. In the event I am not available or not reachable, I give permission for Arthritis, Autoimmune and Allergy, LLC to leave a voice message on a voice messaging device. I give permission for Arthritis, Autoimmune and Allergy, LLC to release information verbally regarding my medical records, test results, appointment details or additional information to person(s) listed below:

Name

Contact Number

Relationship

Name

Contact Number

Relationship

Name

Contact Number

Relationship

To add additional fields click the + icon located on the right side of any field.

Patient Signature - Release of Medical Information(Required)

Date - Release of Medical Information

MM slash DD slash YYYY

If you wish to remove or add additional person(s) to this form you will need to fill out a new form and submit it to our office. Any revocation of consent is to be made in writing and submitted to Arthritis, Autoimmune, and Allergy, LLC.

Initial Patient Health Survey

Reason for your visit (chief complaint):

Do you smoke?

Yes

Are you a former smoker?

If yes, how often do you smoke?

If you are a former smoker, when did you quit (approximately)?

Personal Past Medical History

Do you now or have you ever had the following conditions?

Anemia

Kidney Disease

Pleurisy

Lupus

Psoriasis

Blood Clots

Thyroid Disease

Anxiety

Alcohol/Drug Addction

Chronic Headaches

Depression

Irritable Bowel Syndrome

Fibromyalgia/ Chronic Pain

Heart Disease

Asthma

Chronic Obstructive Pulmonary Disease

Diabetes

Stroke

Colitis

High Blood Pressure

Tuberculosis

HIV/ AIDS

Covid-19

Cancer

To add additional fields click the + icon located on the right side of any field.

Other known conditions:

Do you have any known drug allergies?

Yes

If you do have drug allergies, please list:

Medication History

Name of Medication

Strength & Dosage

To add additional fields click the + icon located on the right side of any field.

Surgical History

Surgery

Year

Reason

To add additional fields click the + icon located on the right side of any field.

Family History

Please list what family member if any, has the following conditions:

Osteoporosis

Lupus

Rheumatoid Arthritis

Ankylosing Spondylitis

Psoriasis

Hay Fever

Allergy History

Please select all of the following you are or have been affected by:

Environmental History

Seasonal Perennial

Symptoms Induced by

Pets

Asthma

Dust

Plants

Rhinitis

Animals

Grass/Trees (near home)

Conjunctivitis

Cut Grass

Mattress

Otitis

Season Change

Pillow

Eczema

Weather Change

Blankets

Sinusitis

Insecticides

Blinds/ Curtains

Nasal Spray Use

Smoke/Fumes

Rugs

Angioedema

Odors

Stuffed Animals

Urticaria

Cold

Heating System

Insect Allergy

Food

Air Conditioning

Dermatitis

Asprin

Humidifier

Insect Allergy

Exertion

To add additional fields click the + icon located on the right side of any field.

Please list any other things you are affected by:

List more details, if possible, to the items you selected under the "Symptoms Induced by" column

Self Evaluation

A. Dress yourself Including tying shoelaces and doing buttons?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

B. Get In and out of bed?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

C. Lift a full cup or glass to your mouth?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

D. Walk outdoors on flat ground?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

E. Walk outdoors on flat ground?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

F. Turn faucets on and off?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

G. Bend down to pick up clothing from the floor?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

H. Get In and out of a car, bus, or airplane?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

I. Walk two miles if you wish?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

J. Participate In recreational activities and sports as you would like, If you wish?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

K. Participate In recreational activities and sports as you wish

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

L. Get a good night's sleep?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

M. Deal with feelings of a rudely or being nervous?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO

N. Deal with feelings of depression or feeling blue?

WITHOUT ANY DIFFICULTY

WITHOUT SOME DIFFICULTY

WITH MUCH DIFFICULTY

UNABLE TO DO