Patient Registration Form
Hello!


Before you begin filling out this form, please be sure YOU AGREE AND CONSENT to these things:

1) SUBMITTING THIS FORM ELECTRONICALLY, AS WELL AS TYPING YOUR NAME AND CLICKING ON THE FINAL "SUBMIT" BUTTON AS YOUR ELECTRONIC SIGNATURE.

2) ENTERING YOUR EMAIL ADDRESS, AND RECEIVING A COPY OF ALL OF YOUR RESPONSES AT THAT EMAIL ADDRESS.  This allows us to insure that we connect the responses to this form with a valid person and address on the other side.

IF YOU DO NOT AGREE TO THESE THINGS,  please DO NOT CONTINUE filling out this form.  You may access a printable copy of these documents at jhomd.com

By filling out this form and accepting the terms below, I recognize that electronic communication does not have any guarantee of privacy, and that a third party may be able to access my protected health information (PHI).  However, due to the increased convenience offered by the use of methods such as online forms, email, text messages, and faxes, I consent to their use to transmit my PHI.

Should I wish to withdraw my consent at any time, I understand that I must notify James C Ho MD, or his staff in writing of the withdrawal of my consent.

I will choose an option below consistent with the methods of communication I prefer.

PLEASE CHOOSE AN OPTION BELOW:

OPTION 1:

I understand the risks of transmitting protected health information via non-secure methods and do hereby give permission to James Ho MD and his staff, to communicate with me and transmit my protected health information via non-secure means including, but not limited to, email, online forms, text messages, and faxes.

OPTION 2:

I DO NOT want my protected health information transmitted via email, online forms, text messages, or faxes.  I understand this means that I will not be able to use the online scheduling system, nor will I be able to receive statements, bills, notes, documents, or appointment updates, reminders, or changes via email or text messages.  I understand that ALL COMMUNICATION BETWEEN ME AND DR JAMES HO AND HIS STAFF WILL OCCUR OVER THE PHONE, IN PERSON, OR BY THE PHYSICAL (POSTAL) MAIL SYSTEM.  I also understand that, at a future date, if I communicate with Dr James Ho and his staff via email or text message that I am waiving my right to methods of secure communication and am choosing OPTION 1, above.
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Email *
BY CHOOSING EITHER OPTION 1 OR OPTION 2 BELOW, AND TYPING MY NAME, I HEREBY ACCEPT THE TERMS LISTED ABOVE / AL ELEGIR LA OPCIÓN 1 U LA OPCIÓN 2 A CONTINUACIÓN, Y ESCRIBIR MI NOMBRE, ACEPTO LOS TÉRMINOS ANTERIORES / 通过选择下面的选项1或选项2,然后键入我的名字,我在这里接受上面列出的条款 *
Print Name Below to Indicate Acceptance of these Terms. Please print parent or guardian's name if the patient is a minor / Escriba el nombre a continuación para indicar la aceptación de estos Términos. Escriba en letra de imprenta el nombre del padre o tutor si el paciente es menor de edad / 在下方打印名称以表示接受这些条款。如果患者未成年人,请打印父母或监护人的姓名 *
What is the patient's first name? / Nombre / 名 *
What is the patient's last name? / Apellido / 姓 *
What is your birth date / Cuál es tu fecha de nacimiento / 你的生日是什么 *
MM
/
DD
/
YYYY
What is your (the patient) age? / Edad / 你几岁 *
What is your street address? / Dirección / 你的街道地址是什么 *
City, state / Ciudad, Estado / 市,州 *
Zip code / Código postal / 邮政编码 *
Cell Phone #? Número Celular / 手机号码
Cell Phone Number
Yes / Si / 是
No / 不
OK to contact cell regard appt? ¿Podemos comunicarnos para la cita? / 可以联系预约事吗?
OK to leave cell a message? / ¿Deberíamos dejar un mensaje? / 可以留言吗?
Clear selection
Home Phone Number / Número de teléfono de casa / 家庭电话号码 *
Home Phone Number
Yes / Si / 是
No / 不
OK to contact regard appt? ¿Podemos comunicarnos para la cita? / 可以联系预约事吗?
OK to leave a message? / ¿Deberíamos dejar un mensaje? / 可以留言吗?
Clear selection
Work Phone Number / Número de teléfono del trabajo / 工作电话号码
Work Phone / Teléfono del trabajo / 工作电话
Yes / Si / 是
No / 不
OK to contact work # regard appt? ¿Podemos comunicarnos para la cita? / 可以联系预约事吗?
OK to leave a message at work #? / ¿Deberíamos dejar un mensaje? / 可以留言吗?
Clear selection
What is your email? / ¿Cuál es tu dirección de correo electrónico? / 您的电子邮件地址是什么?
Email / correo electrónico / 电子邮件
Yes / Si / 是
No / 不
OK to contact email regard appt? ¿Podemos comunicarnos para la cita? / 可以联系预约事吗?
OK to leave message by email? / ¿Deberíamos dejar un mensaje? / 可以留言吗?
Clear selection
Sex / Sexo / 性别 *
Marital Status
Clear selection
Social Security Number / Número de seguridad social / 社会安全卡号码 *
Driver's License Number / Número de carnet de conducir / 驾驶执照号码 *
Primary Language / Lenguaje primario / 主要语言
Do you need an interpreter? / ¿Necesitas una intérprete? / 你是否需要翻译员
Clear selection
How Were You Referred to Our Office / ¿Cómo fue remitido a nuestra oficina? / 您如何知道我们的诊所?
Clear selection
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