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Wednesday, February 22, 2012
Patient Registration Form Step 1
Please fill out the form below as accurately as possible. This enables us to process our records much more efficiently, which enables us to better serve our patients. If you have any questions do not hesitate to contact us.
Family Health Care Associates of Greenbrier collects and uses your personal information to operate our clinic and deliver the services you have requested. We will not share your personal to any third party source, as it is strictly used for our patient records.
Today's Date:*
Last Name:*
First Name:*
Middle Initial:*
Sex:*
--Please Select--
Male
Female
SSN:*
Date of Birth:*
Occupation:*
Address:*
City:*
State:*
Zipcode:*
Cell Phone:
Work Phone:
Emergency Contact:*
Emergency Phone:
Employer:
Employer's Address:
Spouse and/or Responsible Party (If other than patient):
Responsible Party Address:
Responsible Party Employer:
Responsible Party DOB:
I am:*
Single
Married
Employed
F/T Student
P/T Student
Other
Primary Insurance:*
Please tell us the Insured Name, your Relationship to the Insured, and the Policy and Group Number
Secondary Insurance:
Please tell us the Insured Name, your Relationship to the Insured, and the Policy and Group Number
Insurance Authorization: I assign to the Provider any and all benefits from any insurance plans and direct and authorize such benefits to be paid directly to the Provider. I authorize the release of any medical information necessary to process any insurance claim.
Who may we leave messages with
at your home or work?
May we leave appointment reminder messages on your answering machine?
Home:*
Yes
No
Work:*
Yes
No
May we leave account balance information on your answering machine?
Home:*
Yes
No
Work:*
Yes
No
May we send your lab and pathology results by mail?*
Yes
No
If you answered NO to any of the previous questions, is there another number where we may leave messages regarding appointments, account information, lab, and pathology results?
Contact Name/Phone:
By clicking the SUBMIT button below you hereby authorize us to collect the sent data for pre-registration purposes.
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Developmental Coordination Disorder
Children showing difficulty carrying out routine actions, such as getting dressed, playing with particular types of games, drawing, copying from the board in school and even typing at the computer,
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Lisdexamfetamine Dimesylate Approved For
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No Association Between Stimulant
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How Stimulants Work To Control
It has long been known that psychostimulant drugs have the paradoxical effect of reducing hyperactivity. [Psychostimulant drugs include methylphenidate - known by the trade names Ritalin, Concerta,
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Multiple Exposure To Anesthesia
Mayo Clinic researchers have found that multiple exposures to anesthesia at a young age are associated with higher rates of attention-deficit/hyperactivity disorder (ADHD). Children exposed to two or
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Anesthesia Exposure Linked To ADHD In
A study by researchers at Mayo Clinic, Rochester Minn., and published in Mayo Clinic Proceedings, reveals that children who have been under anesthesia many times when they are young have a greater
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Positive Response For Children With ADHD
While pharmacologic agents have a demonstrated efficacy in children with Attention-deficit/hyperactivity disorder (ADHD), some children have suboptimal response to a single pharmacologic agent. A
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Gestational Diabetes Linked To ADHD Risk
According to a report Online First by Archives of Pediatrics & Adolescent Medicine, babies who are born to mothers with diabetes during their pregnancy and/or living in low income households, have a
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Adderall Shortage Set To Continue
Adderall is a stimulant used to treat ADHD, but it's also a controlled substance due to the addictive qualities of the drug. The DEA (Drug Enforcement Agency) monitors and controls how much of the
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