Joel Rivera, M.D.Jacob Tal, M.D. & Maria Torres, M.D. Acct#______

Patient Name ______Drivers Lic # ______

Address: ______City, St, Zip ______

Telephone: Home (_____) ______Work (_____) ______

Cell Phone # (_____)______Email address:______

Check One: Employed____ F/T Student _____ P/T Student _____ Unemployed _____

Check One: Single _____ Married _____ Other _____

Patient Information Spouse orParent

Employer/School______Name______

Emp/Sch Address ______Work Number ______

SS# ______SS# ______

Date of Birth ______Date of Birth______

(your ssn is required if you have insurance)

In case of emergency, contact: ______Relationship: ______

Work Phone: ( ) ______Cell Phone: ( ) ______

Insurance Information:

Primary Insurance Secondary Insurance

Ins Co ______Ins Co ______

Race: ______Ethnic Group-circle one: Non-Hispanic/ Hispanic

Occupation: ______Language-circle one: English / Spanish / Other

**Phone calls after office hours that result in treatment will generate a cost to your account**

Assignment of Insurance Benefits and Authorization to Release Information:

I authorize payment of medical benefits to Pink Women's Center.for any and all services not paid in fullat the time those services are rendered.I authorize Pink Women's Center to release any medical information as may be necessary for thecompletion of my insurance claims to any insurance carrier, health or hospital plan. I understand that I will be responsible for collection fees of 30% of any balance if my account is sent to collections.

Patient ______Date______

Patient’s Legal Guardian/Agent ______Date ______

Date ______Name ______Age______

Patient Name ______

Reason for today’s visit: ______

______

What changes have there been in your life recently? ______

Pharmacy Name______Address______Zip______Phone______

Do you need 1 month or 90 day prescriptions? ______

Past History: Circle all that apply

Arthritis High Blood Pressure Other Kidney Disease: Pneumonia

Asthma Other Heart Disease: ______Other Lung Disease:

Breast Tumor ______Migraine Headaches ______

Diabetes High Cholesterol Mitral Valve Prolapse Rheumatic Fever

Heart Attack Intestinal Bleeding Neurological Disease Thrombophlebitis

Heart Murmur Kidney Infection Osteoporosis Thyroid Problems

Hepatitis Kidney Stone Paralysis Other: ______

Type of surgery Approximate Date Type of Surgery Approximate Date

1. ______4. ______

2. ______5. ______

3. ______6. ______

Number of: Pregnancies _____ Deliveries _____ Miscarriages ____ Abortions_____ Living children____

Please list previous pregnancies in chronological order:

Date Sex Wt Anesthesia /Complications

___/___/___ M / F ______Vaginal / CSection

Will you permit a blood transfusion for medical reasons? ______

Date of last menstrual period______Are your periods regular?______

Any problems with periods?______Present type of birth control______

Do you want to change birth control?______To what?______

Have you ever had an abnormal Pap Smear?______Treatment?______

Patient Name ______

Did your mother take DES or other hormones while pregnant with you?______

With respect to your female organs, have you ever had: Circle all that apply

Abnormal bleeding Herpes Infection Tubal (Ectopic) Pregnancy

Chlamydia/Gonorrhea/Syphilis Infections of the Tubes or Ovaries Tumor of the Uterus or Ovaries

Genital warts

List all currently used medications: ______

______

List all allergies to medications: ______

Genetic: If of African American or Indian descent, have you or your husband had Sickle Cell carrier testing? Circle one: yes / no

If of Italian or Greek descent, have you or your husband had Thalassemia carrier testing?

Circle one: yes / no

If of Jewish descent, have you or your husband had Tay-Sachs carrier testing? Circle one: yes / no

Additional explanation of past history: ______

Do you drink alcohol?_____ If yes, estimated number of drinks, beers, glasses of wine per week? ______

Do you smoke? ______How many packs a day? ______

Are you using any other drugs? ______Type: ______

Are you sexually active? _____ Any difficulties or discomfort? ______

Family History: Is there a member of your family with a history of:

______Cancer – Type: ______Who? ______

______Congenital(Inherited) Disease Who? ______

______Diabetes Who? ______

______Heart Disease Who? ______

______High Blood Pressure Who? ______

______High Cholesterol Who? ______

______Kidney Disease Who? ______

______Mental Retardation Who? ______

______Osteoporosis Who? ______

______Twins Who? ______

Date of last Pap Smear ______Results ______

Date of last Mammogram ______Results ______

Date of last Bone Density ______Results ______

Date of last Colonoscopy ______Results ______

Pink Women's Center

Patient Signature Page

Patient Name: ______Account #: ______

Financial Responsibility

I have received, read and understand the Patient Financial Policy from Pink Women's Center and I further agree to be bound by the terms stated therein. I also understand and agree that Pink Women's Center may amend such terms from time to time.

Signature: ______Date: ______

Name of Signee, if other than patient: ______

Relationship to the patient: ______

Acknowledgement of Receipt of Notice of Privacy Practices

I, the undersigned, hereby acknowledge the receipt of a copy of the Notice of Privacy Practices of Pink Women's Center.

Signature: ______Date: ______

Name of Signee, if other than patient: ______

Relationship to the patient: ______

12-1-16