BRADENTON WOMEN’S CENTER
Surichya Surattanont MD FACOG
PATIENT REGISTRATION
Name___________________________________________Referred by__________________
Address_____________________________________________________________________
City____________________________________State_______________Zip_______________
Social Security_____________________Date of Birth____________________Age__________
Home Phone___________________________Cell Phone______________________________
Work Phone____________________________ Extension ____________
*Specifiy which number you prefer us to call first
Spouse’s/Partner’s Name____________________Home/Cell Phone______________________
Friend or Relative Not Living With You (Name)_______________________________________
Address_____________________________________________________________________
City & State______________________________Zip___________Phone__________________
PATIENT’S SIGNATURE
____________________________________________________
(Please Sign Here)
PAGE 1
BRADENTON WOMEN’S CENTER
Surichya Surattanont MD FACOG
ANNUAL UPDATE
Name_______________________________________________________Date____________
DO YOU PRESENTLY HAVE…
General
□Fever/Chills
□Weight changes
□Fatigue
Bone/Muscle/Joints
□Paralysis
□Numbness
□Joint swelling
□Joint pain
Skin
□Rashes
□Changes in moles
□Changes in birthmarks
□Sores that do not heal
Eye/Ear/Nose/Throat
□Vision changes
□Difficulty swallowing
□Neck Mass
□Hearing Loss
□Sinus pain/infection
Cardiovascular
□Chest pain
□Arm or Neck pain
□Palpitations
□Varicose veins
□Leg Swelling
Gastrointestinal
□Constipation
□Diarrhea
□Rectal bleeding
□Stomach pain
□Nausea/Vomit
□Poor appetite
Pulmonary
□Short of Breath
□Chronic cough
□Sputum
DO YOU PRESENTLY HAVE…
□Irregular bleeding
□Painful periods
□Vaginal itching/irritation □Vulvar itching/irritation
□Postmenopausal bleeding □Hot Flashes
□Feeling of something
□Feeling of mass
falling out of vagina
in vagina
DO YOU HAVE A HISTORY…
□AIDS/HIV
□Emphysema
□Alcoholism
□Epilepsy
□Anemia
□Genital Wart
□Arthritis
□Glaucoma
□Asthma
□Gout
□Bronchitis
□Heart Attack
□Cancer
□Heart Problem
□Chlamydia
□Hepatitis
□Diabetes/
□Herpes
Sugar prob
Urinary
□Pain on urinating
□Urine leak
□Frequent urination
□Bleeding between periods
□Pelvic pain
□PMS/Mood swings
□Breast Mass/Pain
□Irr. Bowel Syndrome
□Hypertension/High Blood Press
□Kidney/Bladder
□Liver Disease
□Lung Disease
□Lupus
□Migraines
□Mitral Valve
□Multiple Sclerosis
DO YOU HAVE A HISTORY OF…
□Abnormal mammogram □ Cone Biopsy/LEEP
□Abnormal PAP
□Endometriosis
□Adenomyosis
□ Fibroid Uterus
□Bartholin Cyst
□Lichen Sclerosis
□Breast Disease
□Ovary Cyst/Mass
□ Colposcopy
□Vestibulitis
□Vaginal discharge
□Painful intercourse
□Decrease sex drive
□Breast Discharge
□Parkinson/Alzheimer
□PID
□Pneumonia
□Psychiatric
□Skin Problems
□Stomach/Bowel
□Stroke
□Syphilis
□Thyroid Problem
□Tonsillitis
□Tuberculosis
□Ulcer/Colitis
□Sexual Abuse
MEDICATIONS:
1._________________________________________
2._________________________________________
3._________________________________________
4._________________________________________
Allergies:______________________________________________________
PAGE 2
BRADENTON WOMEN’S CENTER
Surichya Surattanont MD FACOG
Name_________________________________Soc Sec________________Date_________
LIST ALL PREGNANCIES
Vaginal
C-Section
Year
Length of
Place of
Labor/ Wt of baby Delivery
Complications
LIST ALL SURGERIES
Year
Type of Surgery
Physician
Hospital/City
3 LIST ALL HOSPITAL STAYS THAT ARE NOT SURGERY
Year
Illness
Current Age or
Age at Death
Treatment/Medication
Major Illnesses
Mother
Father
Grandmother
Grandfather
Brothers
Sisters
PAGE 3
Cause of Death
Physician
Surgeries
BRADENTON WOMEN’S CENTER
Surichya Surattanont MD FACOG
Patient Consent for Receipt and Transmittal of Protected Health Information
DO WE HAVE PERMISSION TO:
1. Mail notices to your home address
YES________NO________
2. Leave the following information on you HOME answering machine/voice mail :
Appointment Information
YES________NO________
Billing Information
YES________NO________
Medical Information
YES________NO________
3. Leave the following information on your WORK answering machine/voice mail :
Appointment Information
YES________NO________
Billing Information
YES________NO________
Medical Information
YES________NO________
4. I give permission to share APPOINTMENT information and BILLING information with the
person listed below :
Name:_______________________________________________________________________
5. I give permission to share MEDICAL information with the person listed below:
Name:_______________________________________________________________________
Patient Name_________________________________________________________________
Patient
Signature____________________________________________________________________
Guardian
Signature____________________________________________________________________
(If under 18 years old)
PAGE 4
AGREEMENT FOR PROFESSIONAL SERVICES
I understand that by signing below I am consenting to receive professional
services from Bradenton Women’s Center PA, Surichya Surattanont MD, and
the clinical staff. This may include but is not limited to medical services,
medical testing, labs, counseling, and any other intervention deemed
necessary for your well being. I understand that no guarantee or assurance
has been made as to the results that may be obtained from the services
rendered.
I understand the Bradenton Women’s Center PA will bill me for all services
thereafter which may include but are not limited to medical services, medical
testing, lab services, cousultations, school physicals, blood draws, FMLA
forms, filling out Employer or government required forms, record reviews,
counseling, and other medical and alternative health interventions deemed
necessary for your well being. I also understand that I am responsible for
paying out of pocket expenses incurred such as photocopy cost of requested
medical records.
I agree to assign to Bradenton Women’s Center PA any and all third party
benefits to which I may be entitled as a result of the services rendered to me
pursuant to this agreement, including but not limited to Medicare, health
insurance or settlement proceeds and I hereby authorize payment to be made
directly to Bradenton Women’s Center PA.
I understand that different insurance policies have different coverage and I
agree that I am ultimately obligated to pay for all services rendered on the day
they are rendered regardless of whether it is a covered benefit or not under
my insurance policy. I will pay any applicable copay, coinsurance and
deductible for any services rendered at the time that service is rendered. I
authorize the release of protected health information to the extent necessary
to process claims for benefits.
PAGE 5
AGREEMENT FOR PROFESSIONAL SERVICES
PAGE
In the case treatment is being provided to a minor, I consent for
___________________ to any diagnostic procedures including the fully
physical and gynecological exam and all medical, lab, and other services
outlined above that may be deemed necessary to the well being of the minor
under my care/guardianship.
In the event Surichya Surattanont MD or her clinical staff is called to testify in
any legal proceedings concerning the services provided under this
agreement, I will pay for all time incurred, even if called by another party. I
also agree that I will not file suit against Bradenton Women’s Center PA /
Surichya Surattanont MD in any court located outside of Manatee County
Florida unless no courts with jurisdiction exist in that county. I further consent
to venue in said county for all actions that may be brought against me arising
out of this agreement and agree not to seek the transfer of any action to
another county. I understand that protected health information may be
disclosed to the extent necessary for Bradenton Women’s Center to enforce
her rights under this agreement.
I further acknowledge that I may terminate treatment at any time. I also
acknowledge that Bradenton Women’s Center PA, Surichya Surattanont MD
or her clinical staff may terminate treatment at any time for any reason
whatsoever.
My signature below indicates that I have read this agreement and agree to its
terms and also serves as an acknowledgement that I have received notice of
my HIPPA rights.
______________________________________________________________
Patient
Date
_______________________________________________ Minor if applicable
PAGE 6
PAYMENT CONSENT FORM
2
Patient Name
__________________________________________________
Last
Name on Card
First
___________________________________________________
Last
First
I authorize Bradenton Women’s Center PA , Surichya Surattanont MD, (the
“provider”) to charge my card for professional services as follows:
To charge my card for all charges incurred by me with Provider. I understand that
Provider may seek payment from my insurance company prior to charging my card.
However I am ultimately responsible for all charges incurred and authorize payment
from this card for any amounts not actually received by Provider I may revoke this
authorization at any time, except that Provider may charge my card for any charges
incurred prior to receipt of my notice of revocation and may decline to provide further
services until a substitute card is authorize.
If I have questions about any charges, I agree to contact Provider. I agree that I will
not pursue a refund directly through my credit/debit card company, bank or financial
institution. If any of my actions yield a chargeback for any reason, I agree to pay
any and all penalty fee incurred by my provider.
Type of Card
Visa
Mastercard
Discover
Card Number _________ - _________ - _________ Exp Date__________
Security Code ___________
Card Holder Billing Address_______________________________________________
_______________________________________________
Card Holder Signature
________________________________________________
Date
PAGE 7