800 8th Avenue, Ste 616
Fort Worth, TX 76104
Office: (682) 224-3748
Fax: (682) 841-0039
Patient History & Physical Form
Today’s Date: ______________
Patient Name: _________________________
SURGICAL HISTORY
Type of Surgery
FAMILY HISTORY OF CANCER
FAMILY MEMBER
Date of Birth: _________________________________
Year
TYPE OF CANCER
Type of Surgery
DATE DIAGNOSED
Year
LIVING OR DECEASED
LAST COLONOSCOPY:
LAST STRESS TEST:
CANCER SCREENINGS LAST PAP:
CHRONIC MEDICAL CONDITIONS (please circle those that apply to you only)
Diabetes Type I
Ulcers
Hepatitis B
Liver Disease
Diabetes Type II
Epilepsy or Seizures
Hepatitis C
Parathyroid Disease
High Blood Pressure
Thyroid Disorder
H.I.V./AIDS
Asthma
High Cholesterol
Kidney Problems
Hemophilia
Leukemia
Heart Disease
Mitral Valve Prolapse
Sickle Cell Anemia
C.O.P.D.
Heart Attack
Stroke
Cancer
CURRENT MEDICATIONS
MEDICATION ALLERGIES
TOBACCO
How many packs per day?
How long have you smoked?
SOCIAL HISTORY
ALCOHOL
How much do you drink?
How often do you drink?
DRUGS
Do you take any illegal drugs?
If so, when & how often?
800 8th Avenue, Ste 616
Fort Worth, TX 76104
Office: (682) 224-3748
Fax: (682) 841-0039
ASSIGNMENT OF BENEFITS
I, _________________________________________, understand that services rendered to me by Patel
Surgical are my financial responsibility and that Patel Surgical as a courtesy will bill my Insurance Company,
_________________________________________. I authorize my insurance company to pay my benefits
directly to Patel Surgical and I understand that I will be fully responsible for any outstanding balance on my
account.
I have been given the opportunity to pay my estimated deductible and co-insurance at the time of service. I
have chosen to assign the benefits, knowing that the claim must be paid within all states and federal prompt
payment guidelines. I will provide all relevant and accurate information to facilitated the promote payment of
the claim by (Insurance Co.) _____________________________________.
I authorize Patel Surgical to release any information necessary to adjudicate the claim, and I understand that
there may be associated cost for providing information above and beyond what is necessary for the
adjudication of a clean claim.
I understand that should my insurance company send payment to me, I will forward the payment to Patel
Surgical within 48 hours. I agree that if I fail to send payment to Patel Surgical and they are forced to proceed
with the collections process, I will be responsible for any cost incurred by the office to retrieve their monies.
I authorize Patel Surgical to initiate a complaint to the insurance commissioner for any reason on my behalf
and I personally will be active in the resolution of claims delay or unjustified reductions or denials.
Sincerely
Signature of Policy Holder: ____________________________________________________________________
Printed Name of Patient/Guardian: _____________________________________________________________
Date: ____________________________________
800 8th Avenue, Ste 616
Fort Worth, TX 76104
Office: (682) 224-3748
Fax: (682) 841-0039
Permission to Get Records
I, _______________________, with date of birth, _________, give my permission
for____________________________ to give my medical records (as described in p.2) to DR JAY PATEL so that
he can better understand my condition and help me.
PERMISSION TO GET SENSITIVE INFORMATION
By putting initials by each item below, I understand that I give permission for records to be
sent that may contain information about:
_______ My mental health
_______ transmittable disease I may have like HIV/AIDS
_______ Genetic records, and/or
_______ drug and alcohol records
I understand that:
 I do not have to give my permission to share these records.
 If I want to take away the permission for my doctor to get these records, I need to talk to
my doctor or a staff person and sign a paper.
 This form is only good for 3 months from the date I sign it.
Patient Signature: _______________________________________ Date: _______________
Authorized Representative’s Signature:______________________ Date: _______________
Relationship of Authorized Representative _______________________________________
800 8th Avenue, Ste 616
Fort Worth, TX 76104
Office: (682) 224-3748
Fax: (682) 841-0039
Consent for release of medical records for ______________________________________
(Patient’s name)
Date: _________________________
Requesting Records from:
DR JAY PATEL
800 8th Ave, Ste 616
Fort Worth, TX 76104
Office: (682) 224-3748
Fax: (682) 841-0039
Type of Records we are requesting:
Any and all types of records you have for this patient
Doctor visit notes
Doctor’s Orders
Emergency Room Notes
Nurse’s Notes
Urgent Care Notes
Discharge Summary
History and physical
Lab Reports
Hospital Progress Notes
Radiology Reports
Operation or procedure Notes
Consultations
Clinic Notes
Other __________________________
Pathology Reports
Records within the following dates:
All records for this patient
Records dated between ______________________ and ___________________________
Please send records to:
Attention: FRANCES
At Fax Number: 682-841-0039
Or mail to:
800 8th Ave, Ste 616
Fort Worth, TX 76104
For any questions please call (682) 224-3748
And ask for FRANCES
800 8th Avenue, Ste 616
Fort Worth, TX 76104
Office: (682) 224-3748
Fax: (682) 841-0039
Release Your Medical Information to Family
In the event our office would need to release medical information on your behalf to someone
in your family if the family member is not listed on this form we cannot release your medical
information. Please list someone in your family or a friend that you would want to have your
medical information in an emergency.
Patient Name:
_____________________________________________________________________________
Date: _________________________________________________
Name
Phone Number
HM Cell WK
Note: Please Specify if the # is HM/CELL/WK
Please do not include Doctors. Thank you
Relationship