New patient packet .pdf

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Amy Upton Family Practice, PC
1901 Medi Park Drive, Suite #200 / Amarillo, TX 79106
Office phone: 806-420-3550 / Fax: 1-888-613-0381 / On Facebook: Amy Upton Family Practice
Name: ___________________________________________
CURRENT MEDICATIONS:

Date of Birth: _______________
DRUG ALLERGIES:

_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________

_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________

SURGERIES (Procedures and approximate dates):
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
HOSPITALIZATIONS (Other than surgeries listed above):
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
FAMILY MEDICAL HISTORY: (Conditions such as diabetes, coronary
disease, cancer, hereditary aliments, etc.):
Mother: __________________________________

Father: __________________________________

Siblings: __________________________________ Grandparents: __________________________________

Are you: Right _____ or Left _____ handed?
Do you use tobacco, including smokeless tobacco? _________
If Yes, how frequently and what amount? _______________
If No, have you ever smoked? ______________
Do you drink alcohol? Yes _____ No _____ Occasionally _____
If so, how much? __________________

Amy Upton Family Practice, PC
1901 Medi Park Drive, Suite #200 / Amarillo, TX 79106
Office phone: 806-420-3550 / Fax: 1-888-613-0381 / On Facebook: Amy Upton Family Practice
Today's Date: __________________ Date of Birth: __________________
Male: ________ Female: ________
First Name: ___________________________ Middle Initial: _____
Last Name: __________________________
Home Address: ____________________________________________________
City: ____________________________________ State: __________________
Zip Code: __________________
Home Phone: __________________ Work Phone: ___________________
Cell Phone: ___________________
Social Security #:________________________
Email Address: ____________________________________
Marital Status: Single: ________ Married: ________
Divorced: ________ Widowed: ________
What ethnicity(s) do you consider yourself? : _________________
Race(s): __________ Primary language? __________
Name of Employer: ______________________________________
Your occupation: ____________________________
Emergency Contact Name: _________________________________________
Emergency Contact Phone Number: ___________________________________
Relationship: _______________
Please complete if patient is NOT the party responsible for the account,
or is under the age of 18:
Name of Guarantor: _____________________________________________
Relationship to Patient: _______________________
Is insurance under this person's name? __________________
Social Security #: ____________________________________
Date of Birth: ______________________________
Mailing Address: ________________________________________________
City: _____________________________________ State: __________________
Zip Code: ___________________
Additional Information:
Were you injured on the job? Yes: ________ No: ________
If yes, Date of injury: _________________
Were you injured in an auto accident? Yes: ________ No: ________
If yes, Date of injury: _________________

Amy Upton Family Practice, PC
1901 Medi Park Drive, Suite #200 / Amarillo, TX 79106
Office phone: 806-420-3550 / Fax: 1-888-613-0381 / On Facebook: Amy Upton Family Practice
I request payment of authorized insurance benefits be made on my behalf to
the provider indicated above for any services furnished to me. I authorize any
holder of medical information about me or my dependent to release to the
insurance company any information needed to determine these benefits or the
benefits payable for related services. A photocopy of this assignment is
considered as valid as the original until revoked. I understand I am financially
responsible for all charges whether or not covered by said insurance and/ or
Medicare. Should my account go to collection for non-payment, I understand I
will be charged an additional fee to cover the process.

Patient / Guarantor Signature: _________________________________ Date: __________________

Hippa Compliance
We want to protect your right to privacy, but on occasion we may need to
speak to your friends or family regarding your health.
Please list below the people we may speak with, should it be
necessary, regarding your medical condition.
1) ___________________________________________________
Relationship: _____________________
2) ___________________________________________________
Relationship: ______________________
3) ___________________________________________________
Relationship: _______________________
I acknowledge I have been presented with a copy of the Notice of Privacy
Practices for the office of Amy Upton, FNP-BC. The notice details how my
information may be used and disclosed under federal and state law.
*Signature of patient: __________________________ Date: __________
Please print patient's name: ______________________________________
**If not signed by patient, please indicate your relationship to patient
(i.e. parent, guardian, etc.)
Relationship: _________________________

Your phone #: _______________________


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