Adult New Patient Form

Patient Information Sheet

Patients Employer Name:

Patients Employer Address:

Patients Employer City:

Patients Employer State:

Patients Employer Zip:

Patients Employer Telephone:

Person Responsible for Patient (Complete ONLY if Different from Patient):

Guarantor Name:

Guarantor Social Security Number:

Guarantor Date of Birth:

Guarantor Address:

Guarantor Phone Number:

Guarantor Relationship to Patient:

Self

Spouse

Parent

Employers Name:

Employers Address:

Employers City:

Employers State:

Employers Zip:

Employers Telephone Number:

Emergency Contact

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Relationship:

Emergency Contact Telephone Number:

Insurance Information

Primary Insurance Comp:

Primary Insurance Policy Number:

Primary Insurance Group Number:

Primary Insurance Plan Code:

Primary Insurance Subscriber Name:

Primary Insurance Date of Birth:

Primary Insurance SS No:

Secondary Insurance Comp:

Secondary Insurance Policy Number:

Secondary Insurance Group Number:

Secondary Insurance Plan Code:

Secondary Insurance Subscriber Name:

Secondary Insurance Date of Birth:

Secondary Insurance SS No:

How did you hear about our clinic: (Please check to indicate which method?)

Newspaper

Radio

Media

Employer

Family/Friend

Other:

My signature below hereby authorizes the absolved name, insurance company to pay for all medical services rendered. I understand that I am financially responsible for all changes not covered by my insurance company. I authorized release of medical information to said insurance company. Additionally, my signature provides willing consent to procedures which may be performed including emergency treatment and services, and which may include but not to laboratory procedure, x-ray exams, medical or surgical treatment or procedures, anesthesia, or services rendered to the patient under the general and special instruction of the patient's physician or designate.

Signature: (If not Patient, Relationship)

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Date:

Medication List

Please list every prescription and over-the-counter drug you are currently taking. Be sure to include the strength and dosage of each medication, and how often it taken.

Medication Name and Strength:

10.

Direction, How Taking Medication:

10.

Medical History

Are you currently under another physician's care or specialist?

Yes

If Yes, please explain:

Have you ever been hospitalized or has major operation?

Yes

If Yes, please explain:

Medical History

Siblings- Living status

Siblings- Diabetes

Siblings- High Blood Pressure

Siblings- Heart Disease

Siblings- Mental Disorder

Siblings- Cancer (specify)

Maternal Grandmother- Living status

Maternal Grandmother- Diabetes

Maternal Grandmother- High Blood Pressure

Maternal Grandmother- Heart Disease

Maternal Grandmother- Mental Disorder

Maternal Grandmother- Cancer (specify)

Maternal Grandfather- Living status

Maternal Grandfather- Diabetes

Maternal Grandfather- High Blood Pressure

Maternal Grandfather- Heart Disease

Maternal Grandfather- Mental Disorder

Maternal Grandfather- Cancer (specify)

Paternal Grandmother- Living status

Paternal Grandmother- Diabetes

Paternal Grandmother- High Blood Pressure

Paternal Grandmother- Heart Disease

Paternal Grandmother- Mental Disorder

Paternal Grandmother- Cancer (specify)

Paternal Grandfather- Living status

Paternal Grandfather- Diabetes

Paternal Grandfather- High Blood Pressure

Paternal Grandfather- Heart Disease

Paternal Grandfather- Mental Disorder

Paternal Grandfather- Cancer (specify)

Patient Responsibility Form

4. MEDICAL REQUEST FOR PAYMENT

a. I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by Shima Hadidchi, MD.

b. I authorize any holder of medical or other information about me renewed to Medicare and its agents any information needed to determine these benefits for related services.

Date

Print name

(Signature of patient, authorized representative or responsible party)

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PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to attribute it is understood that any dispute as a medical malpractice, that is asked to whether any medical service rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompletely rendered, Will be determined by submission to attribution as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review for attribution proceeding. Parties to this contract by entering into an argument of the constitutional rights to have any such dispute decided in a court of law before a jury, and instead are excepting to use of arbitrated

Article 2: All claims must be attributed it is in intention of the parties the disagreement bind all parties who claims may arise out of or relate to treatment or services provided by the physician including any spouse or heirs of the patient any children whether born or unborn at the time of the occurrence given rise to any claim in the case of any pregnant mother the term "Patient" herein show me what and the mothers expected child or children. All claims for monetary damage exceeding the judicial limit the small claims court against the physician in the physicians partner associates, association, corporation or partnership, and the employees, agents and a state of any of them, must be attribute included, without limitations, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fees from the patient shall wave right to compel attribution of any malpractice claim

Article 3: procedures and Application law: a demand for retribution must be communicated in writing to all parties. Each party shall select an arbitrator "party attribution" within 30 days any third arbitrator (neutral arbitrator) shall be selected by the attribute yours appointed by the party within 30 days of a demand for a neutral attribution by either parties. Each party to the arbitrator shall pay such party's pro rata share the expenses and fees of the neutral arbitrator, together with other expenses of attribution 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 attribute or has the immunity of a judicial office from civil liability when acting in the capacity of attribution under this contract. This immunity shall supplement, not supplant, any other applicable statuary or common-law. Either party shall have the absolute right to attribute separately the issues of liability and damages upon writing request to the neutral arbitrator. The parties consent to the intervention and joinder in this attribution of any person or entity in which what otherwise be a proper additional party in a court action, and up on such intervention and joinder any existing court action against heredity shall be stayed pending arbitration. The parties agree that provision of California law applicable to health care provides shall apply to dispute within this activation agreement, including, but not limited to, code of Civil Procedure section 340.5 and 667.7 in civil court section 3333.1 and 3333.2. Any party may bring before arbitrators a motion for summary judgment or summary arbitration in accordance with the code of civil procedures. Discovery shall be conducted pursuit to code of civil procedure section 1283.05, however the position may be taken without prior approval of the neutral arbitrator.

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 4: General provision: all claims based upon the same incident, the transaction or related circumstance shall be attribute it in one proceeding. A clean shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if assorted in a civil action, would be buried by the applicable California statute of limitations, or (2) the claimant feels to pursue that attribution claim in accordance with the procedure prescribed hearin with reasonable diligence. With respect to any matter not herein express provided for, the arbitrator shall be governed by the California code of civil procedures provision relating to arbitration.

Article 5: Revocation: this agreement maybe revoked permit notice delivered to the physician within 30 days of signature. It is intended of this agreement to apply to all medical services rendered anytime for any condition.

Article 6: Retroactive Effect: a patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

Effective as of the date of the first medical service:

Patients or patient representatives and initial:

If any provision of this arch vision agreement is held invalid running forcible, the remaining provisions shall remain in full force and should not be affected by the invalidating of any other provision. I understand that I have the right to receive a copy of this attribution agreement. By my signature below I acknowledge that I have received the copy.

Notice: By signing this contract you're agreed to have any issue of medical malpractice decided by the neutral attribution that you're giving up your right to jury core trail the article (1) of this contract

Patient or Patient Representative Signature

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Date

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Positions or authorized representative signature

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Date

Patients Name Printed

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Is representative print name and relationship to patient

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Print or step name a physician dr. Shima Hadidchi

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It signed copy of this documentation is to be given to the patient. Originals to be filed in patient’s medical record

SHIMA HADIDCHI MD, A PROFESSIONAL GROUP

INTERNAL MEDICINE, FAMILY PRACTICE

12740 HESPERIA RD, SUITE A VICTORVILLE, CA 92395

PHONE: (760) 998-1999 FAX: (760) 881-3555

(CID : 12760)

Adult New Patient Form

Patient Information Sheet

Patient Information Sheet

Person Responsible for Patient (Complete ONLY if Different from Patient):

Emergency Contact

Insurance Information

How did you hear about our clinic: (Please check to indicate which method?)

Medication List

Medical History

Medical History

FAMILY HISTORY

Medical History

Medical History

Patient Responsibility Form

Patient Responsibility Form

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

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