Physicians’ Wound Center
2770 Eureka Way, Suite 100
Redding, CA 96001
(530)241-2151 Fax: (530)241-2489
NEW PATIENT PAPERWORK
Name:______________________________________________________________
(First)
SS#:_____-___-_____
(Middle Initial)
(Last)
DOB: ____-____-_____
Gender:
Male
or
Female
Mailing Address:_________________________City:____________Zip:_________
Home Phone:_____________________ Cell Phone: ________________________
Email Address: ______________________________@______________________
Referring Physician: _________________________________________________
Primary Care Physician: ______________________________________________
Pharmacy: _________________ Street: _______________ City: ______________
EMERGENCY CONTACT INFORMATION:
Name: _____________________ Relation: _____________ Phone: ____________
VOLUNTARY INFORMATION FOR MEDICARE REPORTING
Ethnicity:
Hispanic/Latino
Non-Hispanic/Latino Patient Declined
Race:
American Indian/Alaskan Native
American/Pacific Islander
Black/African American Multiracial
Asian
White
Preferred Language:
English
DO YOU HAVE HOME HEALTH?
Spanish
Other: ______________________
YES
OR NO
If your answer was YesName of Home Health Agency: _____________________________________
Name of Home Health Nurse: ______________________________________
WHERE IS YOUR WOUND(S) __________________________________________
What treatments do you use on the wound(s)?
___________________________________________________________________
___________________________________________________________________
MEDICATIONS & PAST MEDICAL HISTORY
Drug & Food Allergies:
___________________________________________________________________
___________________________________________________________________
Please list all prescribed and over-the-counter medications you are currently taking.
Medication
Dose
Frequency
Please check any of the following that apply to you:
___Local Anesthesia Problems
___Bleeding Tendencies
___Psoriasis
___Eczema
___Neural Disease
___Hypertension
___Poor Circulation
___Lung Disease
___Hay Fever
___Heart Disease/Murmur/Palpitation
___Recent Weight Loss/Gain
___Tuberculosis
___Hepatitis
___Leg Swelling
___Herpes
___Arthritis
___Keloids
___Migraines/Headaches
___Ulcers
___HIV
___Hives
___Cancer:
___Lupus
___Radiation/Chemotherapy
___Asthma
___Diabetes
___Anemia
___Seizures
___Thyroid
___Hearing Problems
___Kidney Disease/Stones/Recurrent Infections
Social History (please check all that apply)
___ Cigarettes
___ Alcohol
___ Recreational Drugs
___ Coffee
___ Exercise
Please list any Surgeries, Serious illnesses and/ or Hospitalizations:
CONSENT FOR TREATMENT AND BILLING
1. I hereby authorize Physicians’ Wound Center or associates to perform upon me the
named patient the following wound care and/or treatment: WOUND TREATMENT
AND DEBRIDEMENT.
2. The nature and purpose of the wound care and/or other treatment has been fully
explained to me and I have been informed of the expected benefits and complications
(from known and unknown causes), attendant discomforts and risk that may arise, as
well as possible alternatives to the proposed treatment including no treatment. My
questions have been answered fully and satisfactorily.
3. Any tissues removed may be examined and retained by the Physicians’ Wound Center
and its authorized affiliate for medical, scientific or educational purposes and such
tissues or parts may be disposed of in accordance with accustomed practice.
4. I acknowledge that no guarantees or assurances have been made to me concerning
the results intended from the wound care and/or treatment.
5. I herby consent that photographs, tape recordings, video tapes and/or movies may be
taken of me, or the named patient, by Physicians’ Wound Center in connection with
the medical and other services, which, I the patient am receiving at Physicians’ Wound
Center. I further consent that a history of my/the patient’s social and medical
problems may be taken by the Physicians’ Wound Center staff.
6. I understand that neither myself/the patient nor members of my/the patient’s family
will be identified by name in connection with any public use of this material.
7. MEDICARE, I authorize any holder of medical or other information about me to
release to the social security administration or its intermediaries or carries any
information needed for this or a related Medicare claim. I permit a copy of this
authorization to be used in place of the original request payment of medical insurance
benefits either to myself of the party who accepts assignment.
8. ALL OTHERS: I authorize any holder of medical or other information about me to
release any information needed for this or a related claim. I permit a copy of this to
be used in place of the original.
9. I authorize payment of benefits to Physicians’ Wound Center. I understand I am
financially responsible for charges not covered by this assignment, including
coinsurance and deductibles.
10. CANCELLATION POLICY: We require a 24-hour notice for all cancellations and/or
rescheduling. A $30.00 cancellation fee will be charged for those who do not give
proper notice. We are committed to your care and appreciate your commitment to us.
This charge will not apply in some cases of emergency or illness.
I confirm that I have read and fully understand the above and that all blank spaces have
been completed prior to my signing. I have crossed out any paragraphs that do not
pertain to me.
_____________________________________________
__________________________
_____________________________________________
__________________________
Signature of Patient or Person Authorized to Consent for Patient
If Other than Patient, Relationship to Patient
Date
Date