Marghee's Mobile Medical - Patient Information Form
This form includes basic information needed for your Electronic Medical Record. Filling out this form will save us both time and make our visit more efficient. The more complete you are in providing information the more thorough we can be during your appointment.
Please Note: This form follows security protocols which meet HIPAA privacy requirements.
Thank You!
Marghee
Patient Information
Name *
Your answer
Street Address (where you live) *
Your answer
City (where you live)
Your answer
Mailing Address (if different from where you live)
Your answer
City (mailing address - if different from where you live) *
Your answer
Zip Code (mailing address)
Your answer
Best Phone Number to reach you *
(808)XXX-XXXX
Your answer
Best Email Address *
Your answer
Birthdate *
mm/dd/yyyy
Your answer
Social Security Number (optional)
XXX-XX-XXXX
Your answer
Insurance / Payment Information
What Health Insurance do you have? *
if other, please list name
Your answer
Insurance ID#
Your answer
Insurance Group ID#
Your answer
Do you have additional Insurance?
If yes - Please pick from the list below.
Other Insurance ID#
Your answer
Other Insurance Group ID#
Your answer
Allergies
Please list any allergies you have in the appropriate areas below - If you have none please list "None".
Drug Allergies
After listing Allergy - Describe your reaction (mild, moderate, or severe)
Your answer
Food Alergies
After listing Allergy - Describe your reaction (mild, moderate, or severe)
Your answer
Environmental Allergies
After listing Allergy - Describe your reaction (mild, moderate, or severe)
Your answer
Current & Past Medical History
Smoking Status *
Ongoing Medical Problems / Concerns
Please list any medical concerns you have had in the past or currently have.
Your answer
Medications
List any medications you are taking, the dosage and frequency. If none, please write "None".
Your answer
Do you currently have any specific concerns? What do you want to focus on during your appointment with Marghee?
Your answer
Marghee's Mobile Medical (MMM)follows all HIPAA requirements. MMM has the complete HIPAA policy available on www.marghee.com and suggest you read it. MMM will not share your personal or protected health information unless it is required for your continued care and with your express permission. By typing your name below you acknowledge that you understand and or have read Marghee's Mobile Medical HIPAA Policy.
Your answer
Thank You!!!
Thank you for your time and thoroughness in filling out this questionnaire. I look forward to your appointment. By pressing the "Submit" button below we will be more prepared for a productive time together.
Your Partner in Health and Wellness,
Marghee
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