Today's Date:    Office Preference: Select One Dekalb Co. Gwinnett Co. Rockdale Co.

Last Name: First Name: MI: Salute: Nickname:

Social Security: Date of Birth: Gender: Select One Male Female

Address: City: State: Zip:

Home Phone: Email:

Work Phone: Cell Phone:

Employment Status: Select One Employed Not Employed Self Employed Student Retired Occupation: Employer:

Martial Status: Select One Married Single

If Married, list Spouse' Information. If Not Married, List Emergency Contact or Nearest Relative.

Contact Name: Relationship: Select One Spouse Son Daughter Father Mother Brother Sister Aunt Uncle Friend Contact Phone

Spouse-Social Security Number: Spouse-Date of Birth:

Primary Physician: Telephone:

Primary Insurance: ID#: Group#:
Policy Holder Name: Relationship to Patient:
Secondary Insurance: ID#: Group#:
Policy Holder Name: Relationship to Patient:

MEDICAL RELEASE AND LIABILITY WAIVER, authorize consent for medical treatment & permission to ANRC, to supervise/perform on site first aid for minor injuries & to a licensed physician to hospitalize & secure proper treatment (including injections, venipuncture or other necessary procedures).

I understand that it is my responsibility to provide accurate medical insurance information to ANRC. I understand it is my responsibility to insure, that if required, an insurance referral for specialty care has been obtained. I understand that I am financially responsible to ANRC for co-payments, deductibles and any related medical treatment charges not covered.

RELEASE, DISCLOSURE AND ASSIGNMENT OF BENEFITS
I, authorize the release and disclosure of all or any part of my medical records (via fax machine, mail or electronic data exchange) necessary to assist in the reimbursement of benefits to which I may be entitled to for all or part of the provider charges. I authorize payment directly to ANRC for all services furnished. The signature below shall suffice for all insurance forms on a continuing basis.

I, authorize the release and disclosure of all or any part of my medical records (via fax machine, mail or electronic data exchange) necessary to provide the most appropriate medical care to include other health care providers, treatment facilities or hospitals which may be of assistance in providing for my medical treatment.

I authorize ANRC to contact me or leave medical information pertaining to my care by the above listed methods (mail,voice mail, e-mail or with spouse/contact listed) and I will assume responsibility to notify ANRC whenever the information changes.

I acknowledge, I have been provided an opportunity to review the NOTICE OF PRIVACY PRACTICES, FINANCIAL POLICY , PATIENT RIGHTS & RESPONSIBILITIES. I have read this entire Authorization, Waiver, Release, Disclosure and Assignment of Benefits.

Patient /or Guardian Signature ______________________________________________,

Today's Date:   County:   Last Name:   First Name:  

Today's Date:   County:   Last Name:   First Name:  

Family History (List age of parents, siblings, children with any serious medical conditions. If deceased, list cause of death.)

Men - Continue next page
Women - Complete the following section.

GYN / Obstetrical History
List date of childbirth and any pregnancy-related complications such as diabetes, high blood pressure, protein in urine, etc.

Age at Menopause: Date of last menstural period.

Papsmear: Mammogram:

Today's Date:   County:   Last Name:   First Name:  

ALLERGIES: Have you ever had allergies? Select One Yes No

MEDICATIONS: List all medications including over-the-counter and all vitamin and mineral supplements. Please include all pain relievers.

Today's Date:   County:   Last Name:   First Name:  

REVIEW SYSTEMS (Please check all that apply.)

Today's Date:   County:   Last Name:   First Name:  

CONTINUE REVIEW SYSTEMS (Please check all that apply.)