Online Registration - Dr Woods Hearing Center

Name *

First

Last

Date of Birth//

Email *

Home Phone *

Mobile Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Alternate Contact Information

Alternate Contact Name

First

Last

Relationship to Patient

Alternate's Phone Number

Alternate's Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Care Provider and Insurance Information

Primary Care Physician *

Primary Care Address/City or Town *

Insurance Provider *

Insurance Provider if not listed above

Insurance Identification Number *

Do you have an HMO?

Provider Services Phone Number (On Back of Insurance Card) *

You are required to have a referral from your Primary Care Physician. Fax: 603-889-9531 *

I will have a referral sent to the office prior to my appointment

How Did you Hear About us? *

Patient History

Height and Weight

Reason for Visit *

Previous Treatment for This Problem?

Please List Allergies to Medications *

Medications your are Currently Using *

Social History (please check all that apply)

Alcohol
Tobacco
Other Druges

List any Other Drugs:

Medical/Surgical History *

Family History of Hearing Loss? *

Please Check all That Apply

Checkboxes *

if Weakness, Where?

Patient Acknoledgment HIPPA

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this acknowledgement. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. The Summary of our Notice of Privacy Practices is posted in our main lobby. The complete Notice’ of Privacy Practices in also available in our main lobby for your review. If you would like to receive a copy of the Summary and complete Notice we have one available for you at the front desk. If you wish for persons other than those released under normal operations as indicated in the Notice to receive confidential information that is now protected under this law you must release them in writing. Please indicate on your patient registration form spouse, or any family or friends whom you wish to be able to receive information about you. You may of course choose not to release anyone. You may also be more specific in your restrictions for the persons you have released, just provide that request in writing. Parents or Guardians of minor children do not need to be released. We have found that the easiest way to identify persons who are inquiring about your information is for you to assign a security password to your account. Persons who call will be asked this password instead of your social security information. Please be aware that our staff has to follow federal law on information that we release by phone and we may at any time choose not to release information of any kind by phone if we feel that the person requesting information is not authorized or we feel the information may be too sensitive to release by phone. By signing this form, you are acknowledging that the Dr. Woods Hearing Center has made our Notice of Privacy Practices available to you for review and that we have offered you a personal copy. *

Please Indicate if you DO NOT want us to share any information with a family member or loved one *

Yes
No

If no, please indicate who you would like us to share information with *