Urology Center of South Florida

Patient Registration

PATIENT INFORMATION



Dr Mr Ms Mrs Miss



Male Female


Single Married Divorced Widow

   










 



Dr Mr Ms Mrs Miss



INSURANCE INFORMATION



 



Self Spouse Child Other
 



 



Self Spouse Child Other
 
REFERRING PHYSICIAN










   
EMERGENCY CONTACT



 

Privacy Notice

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES AND PATIENT CONSENT

I acknowledge that I have received and reviewed the Notice of Privacy Practices and Patients' Rights pertaining to this office and its affiliated covered entities, and all my questions have been answered to my satisfaction.

Also, I conset to the use or disclusure of my protected healthcare information by the Urology Center of South Florida, and all its departments, operations, and locations for the purpose of diagnosing or providing treatments, obtaining payment for my healthcare services, or to conduct its healthcare operations that specifically include all satellite locations, billings and administration, laboratory and diagnostic center.

Note:You will be given these forms to sign the day of your visit.


 
 

 
 
AUTHORIZATION

In compliance with HIPAA's privacy rule, it is the policy of this office to allow properly authorized individuals to have access to your protected health information (PHI). This authorization will remain in force until revoked in writing by the patient. Please list below the individuals you wish to have access to your protected health information.

CERTIFICATION

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid to the physician. I understand that I am finacially responsible for any balance. I also authorize the Urology Center of South Florida or insurance company to release any information required to process my claims.


 
 

 
 

Medical History

MEDICAL HISTORY



 
 

 

 

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REVIEW OF SYSTEMS (Check all that apply)

Problems with Anesthesia Have you been told not to take certain types of anesthesia

Chills Fatigue Fever Sweats Weight Loss Live Alone Need help caring for yourself


Blurred Vision Double Vision Eye Pain Eye Discharge Vision Loss

Descreased Hearing Ringing in Ears Ear Pain Hoarseness Pain with Swallowing Nose Bleeds

Shortness Of Breath Ephysema

Chest Pain Heart Attack Agina Heart Murmur High Blood Pressure Palpitations Swelling In Legs Pain Walking

Abdominal Pain Nausea Vomiting Diarrhea Constipation Jaundice Bloody Stools

Back Pain Joint Pain Joint Sweeling Muscle Weakness Arthritis

Dryness Itching Rash

Depression Anxiety Memory Loss
Yes No






Thyroid Disease Diabetes

Abnormal Bruising Easy Bleeding Enlarged Lymph Nodes

Hay Fever Itching HIV Exposure

Stroke Fainting Parkinson Disease Paralysis Disc Problems Alzheimer Back Surgery Convulsions Multiple Sclerosis Sciatica Slipped disc

Pregnancies Menopause Pelvic Infections Could be pregnant Irregular Periods PMS Vaginitis Abnormal pap smear