Patient Forms

It is very important that we have as much medical information about you as possible before your visit. In order to expedite your appointment, please fill out the forms below.

Thank you in advance for your help. We look forward to seeing you soon!

PATIENT INTAKE FORMS

INSURANCE COVERAGE

PRIMARY INSURANCE

ID #

GROUP #

PRIMARY CARD HOLDER

SELF

SPOUSE/PARTNER

OTHER

NAME OF INSURED

INSURED DATE OF BIRTH

SECONDARY COVERAGE

YES

SECONDARY INSURANCE

ID #

GROUP #

SECONDARY CARD HOLDER

SELF

SPOUSE/PARTNER

OTHER

NAME OF INSURED

INSURED DATE OF BIRTH

EMERGENCY CONTACT

PRIMARY EMERGENCY CONTACT

First Name

Last Name

PRIMARY EMERGENCY CONTACT PHONE NUMBER

AUTHORIZATION PERMISSION OF PHI

I AUTHORIZE

I DO NOT AUTHORIZE

RELATIONSHIP

SECONDARY EMERGENCY CONTACT

First Name

Last Name

SECONDARY EMERGENCY CONTACT PHONE NUMBER

AUTHORIZATION PERMISSION OF PHI

I AUTHORIZE

I DO NOT AUTHORIZE

RELATIONSHIP

CIRCLE OF CARE

REFERRING PROVIDER

PHONE NUMBER

PRIMARY CARE PROVIDER

PHONE NUMBER

CARDIOLOGIST

PHONE NUMBER

ONCOLOGIST

PHONE NUMBER

PAIN MANAGEMENT

PHONE NUMBER

PHARMACY

NAME

PHONE

ADDRESS

CITY

ZIP

MEDICATION ALLERGIES

DRUG ALLERGIES?

YES

ARE YOU ALLERGIC TO THE FOLLOWING

LIST ALLERGIES HERE

CURRENT MEDICATIONS

MEDICATION NAME

DOSE

FREQUENCY

REASON PRESCRIBED

Add Remove

PRIOR SURGERIES/PRIOR HOSPITALIZATIONS

PRIOR SURGERIES AND DATE

PRIOR HOSPITALIZATIONS

Add Remove

REASON FOR VISIT

NEW PATIENT

SECOND OPINION

ESTABLISHED PATIENT WITH NEW SYMPTOMS

PATIENT SYMPTOMS -BRIEF DESCRIPTION

TEXAS NEUROSURGERY ACKNOWLEDGEMENT FORM

I consent to receive the following documents electronically which are available through our website, unless I request a non-electronic paper copy of the documents disclosed herein.

PATIENT CONSENT

Texas Neurosurgery’s Notice of HIPAA Privacy Practices

Texas Neurosurgery’s Financial Policy

Texas Neurosurgery’s Medication Policy/Agreement

Texas Neurosurgery’s Physician Assistant Information Guide

Texas Neurosurgery’s Disclosure of Physician Ownership

I authorize: The release of any medical and/or other information necessary to process my claim(s)

Payment of medical benefits to my treating physician or supplier for services rendered by Texas Neurosurgery

Consent for treatment by my treating physician with Texas Neurosurgery

I have read and understand/agree to abide by all the above policies and authorizations of Texas Neurosurgery

Patient Signature

Clear

Date

PHYSICIAN ONLY SECTION –PLEASE DO NOT SIGN HERE–

I HAVE REVIEWED THE LISTED ROS/PFSH/SCREENING WITH THE PATIENT AND NOTED THE POSITIVE/NEGATIVE FINDINGS FOR THE VISIT.

M.D. SIGNATURE:

Clear

Date

If you are human, leave this field blank.

PATIENT INFORMATION

INSURANCE COVERAGE

EMERGENCY CONTACT

CIRCLE OF CARE

PHARMACY

MEDICATION ALLERGIES

CURRENT MEDICATIONS

REVIEW OF SYSTEMS

PERSONAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY

PRIOR SURGERIES/PRIOR HOSPITALIZATIONS

REASON FOR VISIT

CONSERVATIVE THERAPIES

TEXAS NEUROSURGERY ACKNOWLEDGEMENT FORM

PHYSICIAN ONLY SECTION –PLEASE DO NOT SIGN HERE–

DALLAS OFFICE

OFFICE LOCATION DETAILS

DISCLAIMER