adult patient_forms_english - Santa Barbara Neighborhood Clinics

In an effort to save time for our patients and clinic staff we have provided the necessary
medical and dental forms needed prior to seeing a Clinician. If you are a new patient or an
existing patient with information that has changed, please click on the appropriate link below
to download and print the necessary forms.
Please bring the filled out forms with you and make sure to arrive 15 minutes before your
appointment. If you have any questions please call the Clinic where your appointment is
scheduled. Thank You!
Authorization and Consent for Photography
AUTHORIZATION AND CONSENT FOR PHOTOGRAPHY
AUTORIZACIÓN Y CONSENTIMIENTO PARA USO DE FOTOGRAFÍAS
Patient Name: ID: DOB: Gender:
The undersigned herby authorizes Santa Barbara Neighborhood Clinics to photograph . The undersigned agrees that the above named
organization may not use and permit other persons to use the negative print prepared from such photograph for any purpose other
than the dental record.
La persona que aquí firma da su autorización por este medio a Las Clínicas de Santa Barbara Neighborhood, para tomar fotos . La
persona que aquí firma está de acuerdo en que la organización arriba mencionada, no pueda usar y permitir que otras personas utilicen
las impresiones negativas pareparadas por este fotógrafo para otro fin más que el expediente dental.
I, decline to have my photograph taken.
Yo, me niego a ser fotografiado.
Signature: Date:
file:///D|/...ar/AppData/Local/Microsoft/Windows/Temporary Internet Files/Content.Outlook/694QQG4M/SBNC Consent Photography.html[9/25/2012 10:13:13 AM]
SBNC Consent for Evaluation and Treatment
& Acknowledgment of Notice of Privacy Policies
I hereby request and consent to the performance of primary care services by a clinician of the
Santa Barbara Neighborhood Clinics (henceforth referred to as SBNC). I do not expect the
clinician to be able to anticipate and explain all risks and complications of the treatment to me.
I understand that, in general, the medical care received at all of SBNC is confidential. I
understand that the expectations required by State law to be reported are: positive results of
certain diseases (such as gonorrhea, syphilis, Hepatitis A + B, Mumps, AIDS, Lyme Disease);
sexual abuse, current or in the past, when the victim under the age 18; abuse of dependent
adults or the elderly; or domestic violence.
I hereby acknowledge that I have been offered a copy of the Notice of Privacy Policies of SBNC
and consent to each of those policies as set forth in the current notice as posted in the
reception area of the clinic.
I understand that information about my medical care may be shared among practitioners
employed by SBNC. I authorize the release of any medical or other information necessary to
make referral appointments and I authorize SBNC to receive reports from any referral provider.
I understand that if follow-up visits to SBNC or to referral providers are needed, I assume
responsibility for completing such follow-up visits.
I hereby give my permission to the employees of SBNC to use the information contained in my
medical record for statistical purposes on a confidential basis.
If laboratory tests are ordered, I understand that a laboratory unaffiliated with SBNC may
perform these tests. I further understand that SBNC is not responsible for reporting erroneous
test results that an unaffiliated laboratory has reported to it.
I understand that I am financially responsible for all charges made at this visit, whether or not
insurance or other third party payer covers them. I authorize the release of any medical or
other information necessary to process insurance or other funding source claim resulting from
my visit.
I understand that I have a right to accept, refuse, or stop treatment at any time.
_____________________________________
________________________
Signature of Patient if 18 years of age or older
Or Patient or Guardian
Date
____________________________________
Print name of signatory
I – 3a.
Updated 2011 | 10
Rushabh
Today’s Date: _____________________________
Patient Name: _________________________________________ Date of Birth: _____________________________
MM/DD/YYYY
Patient Information
Sex: MaleFemale Patient SS#:__________________________ Home Phone:________________________
Alternate Phone: _______________________________ E-mail: __________________________________________
Patient Address: __________________________________________________________________________________
Street Address, City, State, Zip Code
__________________________________________________________________________________________________
Street Address, City, State Zip Code
May we contact you at home? Yes No May we contact you by alternate phone? Yes No
May we contact you by U.S. mail? Yes No May we contact you by e-mail? Yes No
Head of Household (mother, father,
guardian)
Demographics
Marital Status: Single w/partner Single w/o partner Married Divorced Separated Widow/er
Race: (Select one or
more)
American Indian/
Alaskan Native
Asian
Black/ African
American
More than one
race
Native Hawaiian
Other Pacific
Islander
White
Other (Must Specify):
_________________
Ethnicity (select
one):
Hispanic/
Latino
Not Hispanic/
Latino
Refused
Do you smoke?
Yes No
Are you a veteran?
Yes No
Do you have a
language
barrier?
Yes No
Primary
Language:
English
Spanish
Other (Must
Specify):
_______________
Present Living
situation:
Own a Home
Rent a Home,
apartment, or room
Shelter
Street
Doubling up
Transitional
Other:
___________________
Are you an
Agricultural, Cattle,
or Poultry Farm
Worker?
Migrant
Seasonal
Not a farm worker
Do you have permanent housing?
Yes No
How long have you lived there? ______
Do you consider your housing stable?
Yes No
How many times have you moved in
the last year? _______________________
Is there a threat of losing your housing?
Yes No
Have you been homeless in the last 12
months? Yes No
How long have you lived in Santa
Barbara County? ____________________
Is this patient the Responsible Party (over 18 years of age, legally responsible for self)? Yes No
If yes, skip to Household Income at the bottom right of this section.
Responsible party name:_________________________________________________ D.O.B.__________________
Other parent/guardian name:____________________________________________________________________
Relationship to patient:_____________________________________ SS#:__________________________________
Address (if the same as patient, write “same”): ____________________________________________________
Street Address, City, State, Zip Code
_________________________________________________________________________________________________
Street Address, City, State, Zip Code
_________________________________________________________________________________________________
Street Address, City, State, Zip Code
Home Phone:___________________________________ Alternate Phone: ________________________________
Cell Phone:___________________________________ Household Income $____________ Family Size: _______
SBNC20120628Revised20121217Revised20130320
Emergency Contact
Emergency Contact: It is important that we have an Emergency Contact name and phone number
in the event we cannot reach you. We will not disclose personal, confidential information to this person
without your consent. (This number must be different from your phone number).
7123
Name:__________________________________________________ Phone number: ___________________________
Relationship to Patient:_____________________________________________________________________________
May we discuss your medical information with this person? Yes No Is there another person with
whom we can discuss your medical condition in the case that you are incapacitated, or if we cannot
reach you? Yes No If yes provide contact information:
Contact name: ___________________________________________________________________________________
Insurance Information
Phone:____________________________________________________________________________________________
Primary Insurance Name: ________________________________________________ ID #:____________________
Name of Insured, if not patient: ___________________________________________________________________
Secondary Insurance Name:_____________________________________________ ID #:____________________
Name of Insured, if not patient:____________________________________________________________________
Third Insurance Name:____________________________________________________ ID #:___________________
Name of Insured, if not patient:____________________________________________________________________
Miscellaneous
How did you learn about this clinic?
Advertising
Facebook
Health Fair
Printed Ad
CARE/ADMHS
Flyer/Brochure
Insurance
Promoter
SBNC
Employee
Sansum
Church
Friend/Relative
Internet
Radio
Other
Daycare
CenCal Health
Non-profits
Referral
County Clinic
Television
Phone Book
Teen Health Advocate
ER/ED
School
Presentation
Cottage Health System
Acknowledgements: I have executed a copy of the SBNC Consent for Treatment and Evaluation &
Acknowledgement of Receipt of Notice of Privacy Practices and I consent to the matters contained therein. By
signing below I acknowledge that I have received an information sheet on Advanced Healthcare Directives.
Signature of Patient or Responsible Party: ____________________________________________________________________
SBNC20120628Revised20121217Revised20130320
Santa Barbara Neighborhood Clinics
CONFIDENTIAL ADULT MEDICAL HISTORY
Your answers will help us to provide you with the best medical care. Some of the questions may not apply
to you or seem important. Nevertheless, please answer as accurately and completely as you can. This will
become a permanent part of your confidential medical record.
Name: ___________________________ Birth Date: ________ Today’s Date: ________
•
•
•
•
•
•
•
•
List any medications you are allergic to:
______________________________
______________________________________________________
List all medications currently using:
______________________________________________________
______________________________________________________
What are your current medical problems?
______________________________________________________
______________________________________________________
Past hospitalizations/serious Illness: ____________________________________
______________________________________________________
Please list any surgeries/operations: ____________________________________
______________________________________________________
______________________________________________________
Do you smoke cigarettes? YES____ NO ____ # a day______ # of years_____
Do you drink alcohol? Daily___ 1-3/week___ 1-3/month___ Rarely___ Never___
Immunizations:
Year of most recent Tetanus Booster_____________
If you have a vaccination card, please give it to the receptionist to copy
PERSONAL & FAMILY HISTORY: Please check those that apply to you or a family member.
Me Family
____ ____ High Blood Pressure
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
AdultHxEng
11/17/03
Heart Disease
High Cholesterol
Stroke
Asthma
Brochitis
Tuberculosis
Migraine Headaches
Vision problems
Allergies/Hay Fever
Kidney Disease
Urinary Tract Infections
Hernia
Toxic Exposures
Chronic Skin Disorder
Me
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Family
____ Thyroid Problems
____ Diabetes
____ Digestive/Bowel Problems
____ Gallbladder Disease
____ Ulcer Disease/ Acid Reflux
____ Liver Disease/Hepatitis
____ Rectal Bleeding
____ Cancer ________________
____ Depression/Mental Illness
____ Sleeping Problems
____ Seizures/Epilepsy
____ Excessive weight gain or loss
____ Arthritis
____ Anemia
____ Chronic Disease __________
SBNC: SLIDING FEE SCALE ELIGIBILITY DETERMINATION APPLICATION
Income: $__________________ Circle One: Weekly Monthly Yearly
Financial Verification Source and Attach Copy (Circle One):
Tax Return
Check Stubs
Unemployment
Supplemental Security Incom (SSI)
Social Security Disability Insurance (SSDI)
Other:______________________
Family Size: ____________
(Self, spouse and children under 18 years of age)
I certify that under penalty of perjury that I am NOT eligible or currently covered by
CenCal/Medi-Cal, Medicare, or any other private insurance.
I understand payment is due and collected at the time of service.
Initial:
I understand Medications are an additional charge.
Initial:
I understand Labs are an additional charge.
Initial:
I understand procedures are an additional charge.
Initial:
I understand specialty appointments are an additional charge.
Initial:
Patient Name_______________________________________________ Date of Birth:___________
Patient/Parent/Guardian Signature__________________________________Date:_____________
Patient Name:_________________________________ DOB:________________MRN:___________
For Internal Use Only:
Sliding Fee:
Copayment:
Termination Date:
Staff Initials/ Title: