Genninger Patient Medical Histroy

Patient Medical History
Physician
Office Phone*

Area CodePhone Number
Date of last exam
Are you under medical treatment now?

YesNo
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

YesNo
Are you taking any medication(s) including non-prescription medicine?

YesNo
If yes, what medication(s) are you taking?
Do you use tobacco?

YesNo
Do you use controlled substances?

YesNo
Are you wearing contact lenses?

YesNo
Do you have or have you had any of the following?

YesNo
Are you allergic to to or have you had any reactions to the following?

Local anesthetics (e.g. Novocain)Penicillin or any other AntibioticsSulfa drugsBarbituatesSedativesIodineAspirinAny metals (e.g. nickel, mercury, etc.)Option 9Other
Women only:
Are you pregnant or think you may be pregnant?

YesNo
Are you nursing?

YesNo
Are you taking oral contraceptives?

YesNo
Check all that apply:
Financial Arrangements

For your convenience, we offer the following methods of payment. Please check the option you prefer. payment in full at each appointment.
CashPersonal checkCredit cardVisaMastecardI wish to discuss the office's payment policy
Late Charges

If I do not pay the entire new balance within 25 days of the mothly billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed each month (if allowed by law). I realize that failure to keep this account current may result in you being unable to provide additional services except for emergencies or where there is prepaymemt for additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding accouint balances.
Authorizatin and Release

I certify that I have read and understand the above information tro the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information including the diagnosis and the records of any treatment or examination rendered to me ot my child during the period of such health care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the doctor or medical group insurance benefits otherwise payable to me. I understand that my health insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Signature or patient (or parent if minor)*

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Patient Medical History