Adult

_2017 Adult Registration Form – Medical

Patient Information

Gender:
Phone Type
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Spouse / Partner Information

Marital Status:
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Medical History

Are you currently being treated by a physician?
Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you ever had a blood transfusion?
(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Check if you have ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.



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Rheumatology Associates of Long Island

  • Rheumatology Associates of Long Island - 315 Middle Country Rd., Smithtown, NY 11787 Phone: 631-360-7778
  • Port Jefferson Station - 7 Medical Dr., Port Jefferson Station, NY 11776 Phone: 631-928-4885
  • Melville - 1895 Walt Whitman Rd., Melville, NY 11747 Phone: 631-249-9525
  • Staten Island - 1200 South Ave., Suite 307, Staten Island, NY 10314 Phone:
  • Riverhead - 554 E. Main St., Riverhead, NY 11901 Phone:
  • Flushing - 2619 Francis Lewis Blvd., Flushing, NY 11358 Phone:

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