NEW PATIENT INTAKE FORM

PLEASE PRINT AND COMPLETE ALL ENTRIES

FIRST NAME LAST NAME DATE OF BIRTH

____________/____________/____________
SEX SOCIAL SECURITY PHONE NUMBER EMAIL ADDRESS

❑​ Male ​❑​ Female

ADDRESS

CITY STATE ZIP CODE

MARITAL STATUS SPOUSES NAME SPOUSE PHONE NUMBER

❑​SINGLE ​❑​MARRIED
EMERGENCY CONTACT RELATIONSHIP PHONE NUMBER

INSURANCE INFORMATION
DO YOU HAVE INSURANCE? PRIMARY CARD HOLDER PRIMARY POLICY HOLDER NAME

❑​YES ​❑​NO ❑​SELF ​❑S​ POUSE. ​❑​PARENT. ❑

​ ​OTHER______________
PRIMARY INSURANCE COMPANY PRIMARY ID NUMBER PRIMARY GROUP NUMBER

DO YOU HAVE SECONDARY INSURANCE? SECONDARY CARD HOLDER SECONDARY POLICY HOLDER NAME

❑​YES ​❑​NO ❑​SELF ​❑​SPOUSE. ​❑P

​ ARENT. ​❑​OTHER_______________
SECONDARY INSURANCE COMPANY SECONDARY ID NUMBER SECONDARY GROUP NUMBER

PAYMENT POLICIES
● You are financially responsible for anything insurance does not cover. All copays are due and payable at each visit. The amount your insurance will
allow and pay for and your financial responsibility is determined by your insurance company and the policy you have chosen. Your claim will be
processed according to the benefits of your insurance plan. The deductible, co-insurance and co-pay are your financial responsibility. It is your
responsibility to understand your insurance plan.
● $5 Fee for Co-pays not paid at the time of service.
● $50 No Show Fee for any Missed Appointment that was not cancelled or rescheduled 24 hours prior to the appointment. Please be considerate and
call at least 24 hours before your appointment if you cannot come in.
● $35 NSF charge for any returned check from the bank.
● If you are a private patient without insurance, all charges are due at the time of the visit. We do not send a statement to private pay patients.

PRESCRIPTION POLICY

PHARMACY NAME PHARMACY PHONE NUMBER

● Please do not wait until your last pill to call for a refill. There is a 72 hour turn around for prescription refills. If you have not seen the Physician in six
months, the prescription will be Denied.

PATIENT SIGNATURE DATE

 PATIENT MEDICAL HISTORY

Allergies
❑​ ​NONE/Known Allergies ❑​ ​Adhesive Tape ❑​ ​Anesthesia ❑​ ​Aspirin ❑​ ​Codeine
❑​ ​Dairy Products ❑​ ​Iodine/Shellfish/Contrast ❑​ ​Latex ❑​ ​Morphine ❑​ ​Penicillin

OTHER:
FAMILY HISTORY ​– Please indicate if any of your immediate relatives have had any of the following by placing an X in the appropriate box.
MOTHER FATHER
Anesthesia Problems
Arthritis
Cancer
Diabetes
Heart Problems
Hypertension
Stroke
Thyroid Disorder
SOCIAL HISTORY
◻​Yes ​◻​No - ​Do you drink alcohol? ◻​ Daily ​◻​Weekly ​◻​Infrequently ​◻​ Recovering Alcoholic
◻​Yes ​◻​No - ​Do you smoke? ◻​ Smoke ( ___ packs per day) ◻​ Chew
◻​Yes ​◻​No - ​Do you drink caffeine? ◻​ Daily ​◻​Weekly ​◻​Infrequently
◻​Yes ​◻​No – ​Are you sexually active?
◻​Yes ​◻​No – ​Do you wish to be checked for STDs?

Surgical History:​ ​Please list any ​hospitalizations​, ​surgeries​, ​fractures​ or ​major illnesses​ you have had.
TYPE OF SURGERY YEAR or DATE DOCTOR LOCATION

Medical History: ​Have you ​ever​ had any of the following?

❑​ ​NONE of the problems listed ❑​ Chest pain ❑​ Hypertension ❑​ ​Osteoporosis
❑​ Allergies ❑​ Congestive heart failure ❑​ Hypogonadism male ❑​Pulmonary embolism
❑​ Anemia ❑​Chronic fatigue syndrome ❑​ Hypothyroidism ❑​ Seizure disorders
❑​ Arthritis conditions ❑​ Depression ❑​ Infection problems ❑​ Shortness of breath
❑​ Asthma ❑​ Diabetes ❑​ Insomnia ❑​ ​Sinus conditions
❑​ ​Arterial fibrillation ❑​ Drug/alcohol abuse ❑​ Irritable bowel syndrome ❑​ ​Stroke
❑​ Bleeding problems ❑​ ​Erectile dysfunction ❑​ Kidney problems ❑​ ​Syndrome X
❑​ BPH ❑​ ​Fibromyalgia ❑​ Menopause ❑​ ​Tremors
❑​ ​CAD coronary artery disease ❑​ Gerd ❑​ Migraines/headaches ❑​ ​Wheat allergy
❑​ Cancer ❑​ ​Heart disease ❑​ Neuropathy
❑​ Cardiac arrest ❑​ ​Hyperinsulinemia ❑​ Onychomycosis
❑​ Celiac disease ❑ ​Hyperlipidemia ❑​ Organ injury

Medications:​ ​List any medications you are currently taking (please include over the counter medications):
PLEASE PRINT LEGIBLY – NO CURSIVE PLEASE
MEDICATION DOSAGE PRESCRIBING DOCTOR
 HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that
you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or
healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The
HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment,
payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially
anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a
revocation will not be retroactive.

By signing this form, I understand that:

● Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
● ∙​ The practice reserves the right to change the privacy policy as allowed by law.
● ∙​ The practice has the right to restrict the use of the information but the practice does not have to agree to those

restrictions.

● ∙​ The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
● ∙​ The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments? YES NO

May we leave a message on your answering machine at home or on your cell phone? YES NO

May we discuss your medical condition with any member of your family? YES NO

If YES, please name the members allowed:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

This consent was signed by: ____________________________________________________ (PRINTNAME )

Signature: ________________________________________________________________ Date: _________________

 MEDICAL SERVICES AGREEMENT

Medical Consent: ​I consent to any treatments or procedures which may be performed on an outpatient basis (including
emergency treatment or services), which may include but are not limited to medications, injections, taking of medical
photographs, laboratory procedures, and/or x-ray examinations provided to me under the general and special instructions of
the physicians, staff, or other health care providers of The Medical Dock assisting my care.

Financial Agreement: I understand that all charges are due at the time of service. ​I agree to pay The Medical Dock for all
charges for healthcare services and professional services provided to me by physicians and other healthcare professionals.
Acceptable forms of payment include Cash, Visa, MasterCard, Discover, and American Express. If I am a non-insured patient, I
agree to pay for my visit in full at the time of service. If The Medical Dock is a participating provider with my insurance
company, I understand that my co-pay, coinsurance, deductible, and/or any outstanding balances are due at the time of
service. I understand that my insurance policy is a contract between myself and my insurance company, The Medical Dock is
not involved. In order for The Medical Dock to file claims and accept payments from my insurance carrier, I understand that I
must present current insurance information at each visit and that The Medical Dock will need to verify my health insurance
coverage. In the event that The Medical Dock is not able to verify my insurance eligibility and benefits before my visit, I agree
to pay for my visit in full at the time of service. A refund will be issued if my insurance pays for the visit. I also understand that
I am financially responsible for any services not covered by my insurance company. When my spouse or a financial guarantor
signs this agreement, the spouse or the financial guarantor shall be jointly and individual liable with me. Should my account(s)
be referred to an attorney or a collection agency for the collection, the undersigned shall pay the actual attorney’s fees
(including costs) and collections expenses incurred in addition to the other amounts due. Unpaid accounts referred to outside
agencies for collection shall bear interest at the current rate per year from the date of referral.

Insurance Authorization and Release:​ I request the payment of authorized benefits, including Medicare, and any other
government sponsored program, private insurance, and any other health plans to be made to The Medical Dock for any
services furnished by that provider. To the extent necessary to coordinate my health care or determine liability for payment
and to obtain reimbursement for services rendered, I authorize The Medical Dock to disclose portions of or all of my records,
including my medical records to any person or corporation which is or may be liable for all or any portion of The Medical Dock
charges, including but not limited to insurance companies, health care service plans, governmental agencies, or worker’s
compensation carriers. I authorize The Medical Dock to act as my agent to help me obtain any required pre-certification as
well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to
give The Medical Dock any information required to fulfill this function. This will remain in effect until revoked in writing. A
photocopy of this assignment and release is to be considered as valid as the original.

Release of Medical Information:​ I hereby authorize The Medical Dock to release any information in my chart to any
practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize
The Medical Dock to provide a copy of my medical records to my Primary Care Physician (PCP) to allow for continuity of care.

Notice of Privacy Practices:​ By signing this form, you acknowledge receipt of the “Notice Of Privacy Practices” of The Medical
Dock. Our “Notice of Privacy Practices” provides information about how we may use and disclose your protected health
information. We encourage you to read it in full. Our “Notice of Privacy Practices” is subject to change. If we change our notice,
you may obtain a copy of the revised notice by contacting The Medical Dock at (714)596-0400.

In House Pharmacy:​ I understand that, for my convenience, The Medical Dock can dispense some prescription medications
necessary to treat my medical condition(s). I understand that my insurance will not be billed for medications dispensed and
that my pharmacy benefits DO NOT apply to this service. ​Any medication(s) dispensed in the office are my responsibility
and are an additional charge to my office visit charge. ​I also understand that if I prefer to use an outside pharmacy, a
prescription can be provided to me at no additional charge.

Personal Valuables:​ The Medical Dock shall not be liable for the loss of or damage to any money, documents, jewelry, glasses,
dentures, furs, or other articles of unusual value and shall not be liable for loss or damage to any personal property.
The Medical Dock, A medical corporation and the patient or the patient's representative, hereby enters into this agreement.
The undersigned certifies that he/she has read and agree to the foregoing, and is the patient, the patient’s representative or is
duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.

Signature: ________________________________________________________________ Date: _________________

 Physician Patient Arbitration Agreement

Article 1: ​Agreement to Arbitrate​: It is understood that any dispute as to medical malpractice, that is as to whether any medical services
rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be
determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California
law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional
rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: ​All Claims Must be Arbitrated: ​It is the intention of the parties that this agreement bind all parties whose claims may arise out of
or related to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or
unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean the
mother and the mother’s expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s
partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated
including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by
the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: ​Procedures and Applicable Law: ​A demand for arbitration must communicate in writing to all parties. Each party shall select an
arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by
the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro
rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the
neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties
agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this
contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral
arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional
party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be
stayed pending arbitration.

The parties agree that the provisions of California law applicable to health care providers shall apply to disputes within this arbitration
agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any
party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil
Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without
prior approval of the neutral arbitrator.

Article 4: ​General Provisions: ​All claims based upon the same incident, transaction or related circumstances shall be arbitrated in once
proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action,
would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance
with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the
arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: ​Revocation: ​This agreement may be revoked by written notice delivered to the physician within 30 days, or signature. It is the
intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: ​Retroactive Effect: ​If patient intends this agreement to cover services rendered before the date it is Effective as of the date of first
medical services.

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall
not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received
a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL
ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

By: ________________________________________________ Patients Signature