You are applying for Healthcare. Please read carefully before you sign. Fax signed form to 979-776-6280

MAHESH R. DAVE, M.D.P.A OR NALINI M. DAVE M.D.P.A

1201 D Briarcrest Drive Bryan, TX 77802

Patient Name ______Birthday______Age______Sex__ Marital Status ______

Address______City ______State______Zip______

Phone: Home# ______Work# ______Cell #______E-Mail: ______@______

Employer______Position ______Referred by______Reason for visit ______

Guardian/Spouse______Relation ______Employer ______

Social Security Number: ______- ______- ______

Insurance______Group # ______Policy# ______Authorization #______

Medicare #______Medicaid # ______Worker’s Comp ______

This Exam Injury/Accident Related? Yes or No Injury Date ______How Injured? ______

Are You Currently Or Soon Planning To Become a Plaintiff In Law Suit? Yes or No

In Emergency Notify-Name______Tel # ______and 911

May we communicate to you in future via E-Mail /Text? Yes __ No __

My Medical Problems: (Put Y=Yes or N=No. Describe condition on the Back of this Page OR Next Page)

Diabetes ___ High Blood Pressure___ Cancer __ Asthma ___ Heart Problem___ Brain Illness ___ Bleeding ____

Injury ___ Pain ___ Sex Problems ___ Mental Illness ___ Depression ___ Bipolar or Mania __ Tried Suicide ___

Alcoholism ___ Drug Problems ___ Tobacco ____ Surgeries ______Are you Pregnant Now? __ Other _____

I am allergic to ______

My Family History: (Example – grandparent, dad, mom, siblings and children) Put Y=Yes or N=No

Diabetes ___ High Blood Pressure___ Cancer __ Asthma ___ Heart Problem___ Brain Illness ______

Mental Illness ___ Depression ___ Bipolar or Mania __ Tried Suicide ___ Alcoholism ___ Drug Problems ___ Other ______

I apply for and request health care services from doctors above or their designees. WITH MY SIGNATURE BELOW, I certify that Information I have given or will give In future, is and will always be true and correct, and I agree (a) to hold doctors harmless from any and all medical, personal or other liability arising out of my failure or unwillingness to provide correct medical and personal information (b) and give doctors permission to communicate with my Insurance/managed care company as to payment for service and thus release to them all Information, including but not limited to my medical, substance abuse, HIV &/or psychiatric records of diagnosis and treatments (c) to indemnify the doctors, hold them harmless, and free of any professional or personal liability claims by me, my agents or heirs; If any problems with health arise out of my insurance &/or managed care company or its agents delaying or denying access to care recommended by doctor (d) to pay for any and all services rendered to me by doctors (regardless of whether my insurance company agrees to pay or not for any reason) as charges become payable upon receiving health/medical service (e) that I understand doctors’ health/medical/indirect service charges (f) to Indemnify and hold doctors harmless if I fail to comply with prescribed tests, treatments, and follow-up appointments (g) to allow doctors to exchange medical and psychiatric Information with referral source, (h) to update doctors of any and all changes in information above including treatments from all sources, (I) to pay out of my pocket for any and all direct or indirect services rendered by doctors Including but not limited to phone conferences, narcotic prescription management, filling forms, letters, & records, (j) to pay $55 for any appointment not kept or canceled by me without 24 hr. notice, (k) that I may be subject to collection and legal action if I fail to pay outstanding balance owed in full within one month, once such demand is made by the doctors,& (I) that all notices (Including billing, treatment, termination of care and collection) by doctors be mailed by regular non-certified first class U .S. MAIL, to my address above and that such action by doctors will constitute an acceptable, adequate reasonable notice. Having read the above, now, I/We the undersigned request medical or psychiatric care according to similar standards prevalent in similar practices in Bryan & College Station, Texas; and will agree and abide to patient responsibility agreement above,

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Patient Guardian Date

After filling and signing above form, fax to 979-776-6280

Updated 2-18-2010 10.38 pm