New Patient Registration

1General Information

2Medication and Allergies

3Notice of Privacy Rights

4Patient Authorization to Release Protected Health Information

5Medical History

6Social History

7Family History

8History of Present Illness

9History of Treatment

Medications
Name Dose Directions Prescribed by
- No reported medications
Allergies Reaction
- No known allergies
Pharmacy Name
Phone Number
I verify that the listed medications and allergies are accurate to the best of my knowledge. I give permission to verify my medication or narcotic treatment with my primary care doctor and/or other treating physicians.
Signature
Date
MM slash DD slash YYYY

I acknowledge that I have received a copy of MIDISC, PLLC's 'Notice of Privacy Practices'. This Notice described how MIDISC, PLLC may use and disclose my protected health information, certain restrictions of the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.
Patient or Legally Authorized Individual Signature
Date
MM slash DD slash YYYY
With my consent, MIDISC PLLC may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to MIDISC PPLC's Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. MIDISC PLLC reserves the right to revise its Notive of Privacy Practices at anytime. A revised Notice of Privacy practes may be obtained by forwarding a written request to MIDISC PLLC Privacy Officer at 3067 Tamiami Trail Suite 3, Port Charlotte, Fl 33952.

With my consent, MIDISC PLLC may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my my clinical care, including laboratory results among others.

With my consent, MIDISC PLLC may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to MIDISC PLLC's use and disclosure of my protected health information (PHI) to out treatment, payment and healthcare operations (TPO).

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, MIDISC PLLC may decline to provide treatment to me.
Patient or Legally Authorized Individual Signature*
Patients Printed Name
Legal Guardian Printed Name (if applicable)
Date
MM slash DD slash YYYY

Name	Address	City/State/Zip	Relationship	Phone #

Personal Details

Emergency Contact

Insurance

Visit Details

Authorization

Diagnostic History

Medications

Non-Operative Care

Previous Evaluation

Navigation

Driving Directions

We are here for you.

Name	Dose	Directions	Prescribed by

Allergies	Reaction

Type of Surgery	Year	Physician