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RETIREE AND SENIOR CARE
ADULT MEDICINE
FREE TRANSPORTATION
Diagnostic Imaging, Lab Testing, and Pharmacy
About Us
Our approach to your care
Testimonials
Locations
Virtual tour
Forms
NEW PATIENT FORMS
Contact
Facebook
Instagram
Youtube
NEW Patient Registration
Please be prepared to provide the following:
Patient, caregiver or responsible party information
Medical Insurance Information
Medical History
Step
1
of
10
- Disclosure
10%
The following patient registration requires patient information, emergency contacts, medical history, insurance coverage details, social history, family history, and a medical release. Please set aside at least 15 minutes to carefully go through all sections. By proceeding and completing this registration and release form, you agree to the terms/conditions and will enter the information to the best of your ability.
Preferred Location For Visit
(Required)
Kendall
Miami Gardens
Pembroke Pines
Lauderhill - Commercial Blvd
Lauderhill - US441
Coral Springs
Delray Beach
Boynton Beach
Palm Springs
Patient Name
(Required)
First
Middle
Last
Previous Name
Email
Enter Email
Confirm Email
Address
(Required)
Mailing Address
Apt#
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Home Phone:
(Required)
Cell Phone:
Work Phone:
Preferred Method of Contact for Reminder Calls and Other Electronically Generated Messages:
(Required)
Voice
Text
Select Preferred Number:
Home
Cell
Work
Date of Birth:
(Required)
Month
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Social Security #
Hidden
Age
Sex:
(Required)
Male
Female
Transgender
Marital Status:
(Required)
Divorced
Married
Single
Other
Other Marital Status
Who was your previous Primary Care Doctor
Enter your previous physician's name, location and phone number
Employer Name:
Emergency Contact Information:
Emergency Contact Name
(Required)
Relationship to Patient
(Required)
Emergency Contact Phone #
(Required)
Authorized Individuals (Optional):
I would you like to authorize a family member and/or friend, for you to disclose or discuss my Personal Health Information (PHI) to.
(Required)
Yes
No
Authorize Family Member and/or Friend 1
(Required)
First
Last
Authorize Family Member and/or Friend 2
First
Last
Responsible Party - Since Patient is a minor (under the age of 18), the parent or guardian bringing the patient in will be listed as the guarantor:
Name
(Required)
First
Last
Date of Birth
(Required)
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Social Security #
Phone #:
(Required)
Responsible Party - Relationship to Patient
(Required)
Address of Person Responsible
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Additional Information
Language:
(Required)
English
Spanish
Creole
Sign Language
Other
Other Language:
(Required)
Which best describes you?
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial or Biracial
A race/ethnicity not listed here
Decline
Preferred Pharmacy Name
Preferred Pharmacy Location
What type of insurance(s) do you have?
(Required)
I have Primary Medical Insurance only
I have Primary & Secondary Medical Insurance
NONE (Self Pay)
Insurance Information
Primary Insurance
Primary Insurance Company Name
Primary Insurance Policy Holder Name:
Primary Policy Holder's Date of Birth
Primary Insurance Policy Holder's Social Security #
If unavailable, enter Member ID
Primary Insurance Patient Relationship to Policy Holder:
Secondary Insurance
Secondary Insurance Company Name
Secondary Insurance Policy Holder Name:
Secondary Insurance Policy Holder's Date of Birth
Secondary Insurance Policy Holder's Social Security #
If unavailable, enter Member ID
Secondary Insurance Patient Relationship to Policy Holder:
Medical History
Any known allergies?
Are you currently taking any medications or vitamins?
(Required)
Yes ( I am taking medications/vitamins)
No (I'm not taking any medications/vitamins))
List ALL MEDICATIONS you take, including over-the-counter (OTC) medications and vitamins.
Include specific doses and when taken. If you don’t know, please call your pharmacist to confirm.
Medication 1 (Include dosage)
(Required)
Medication 1 (Include dosage)
Medication 2 (Include dosage)
Medication 2 (Include dosage)
Medication 3 (Include dosage)
Medication 3 (Include dosage)
Medication 4 (Include dosage)
Medication 4 (Include dosage)
Medication 5 (Include dosage)
Medication 5 (Include dosage)
Medication 6 (Include dosage)
Medication 6 (Include dosage)
Medication 7 (Include dosage)
Medication 7 (Include dosage)
Personal Medical History (Please check all that apply)
ADHD
Alcoholism
Allergies, Seasonal
Anemia
Anxiety
Arrhythmia (irregular heart beat)
Arthritis
Asthma
Bipolar
Bladder Problems / Incontinence
Bleeding Problems
Cancer
COPD/ Emphysema
Crohn’s Disease
Dementia
Depression
Diabetes Type 1
Diabetes Type 2
Diverticulitis
DVT (Blood Clot)
GERD (Acid Reflux)
Glaucoma
Headaches
Heart Attack (MI)
Heart Disease
Hepatitis
Hiatal Hernia
High Blood Pressure
Kidney Stones
Kidney Disease
High Cholesterol
HIV
Irritable Bowel Syndrome
Liver Disease
Lupus
Macular Degeneration
Neuropathy
Osteopenia/Osteoporosis
Parkinson’s Disease
Peptic Ulcer
Peripheral Vascular Disease
Psoriasis
Pulmonary Embolism (PE)
Rheumatoid Arthritis
Seizure Disorder
Sleep Apnea
Stroke
Thyroid Disorder
Ulcerative Colitis
Last Menstrual Period Date:
Last Mammogram Date:
Last Pap Date:
Last Colonoscopy Date:
Last Dexa (Bone Density) Date:
Pap Details
Normal
Abnormal
Mammogram Details
Normal
Abnormal
Menstrual Period Details
Normal
Abnormal
Colonoscopy Details
Normal
Abnormal
Dexa (Bone Density)
Normal
Abnormal
Other medical problems not listed above:
Have you ever had any surgeries?
(Required)
Yes
No
Surgical History: Please list all prior surgeries and approximate dates performed.
Surgical History
(Required)
Surgical History (continued)
Surgical History (continued)
Surgical History (continued)
Education Level
Elementary
High School
Vocational
College
Graduate / Professional
Are there any VISION problems that affect your communication?
(Required)
Yes
No
Are there any HEARING problems that affect your communication?
(Required)
Yes
No
Are there any limitations to understanding or following instructions (either written or verbal)?
(Required)
Yes
No
Current Living Situation (Check all that apply):
(Required)
Single Family Household
Multi-generational Household
Homeless
Shelter
Skilled Nursing Facility
Other
Current Living Situation (Other)
Smoking / Tobacco Use
(Required)
Current
Past
Never
Type of Smoking
Amount/Day
Number of Years
Alcohol Use?
(Required)
Current
Past
Never
Current/Past Drinks per Week
Recreational Drug Use
(Required)
Current
Past
Never
Type of Recreational Drug Use
Are you sexually active?
(Required)
Yes
No
Are there any personal problems or concerns at home, work, or school you would like to discuss?
(Required)
Yes
No
If yes, please explain below.
Are there any cultural or religious concerns we should be aware of?
(Required)
Yes
No
If yes, please explain below.
Are there any financial issues that directly impact your ability to manage your health?
(Required)
Yes
No
If yes, please explain below.
Comments (Please Explain)
How often do you get the social and emotional support you need?
(Required)
Always
Usually
Sometimes
Rarely
Never
Family History
Father
Father's Living Age:
Father's Deceased Age:
Family History (Father)
Alcoholism
Bipolar Disorder
High Cholesterol
Osteoporosis
Anemia
Cancer
High Blood Pressure
Stroke
Asthma
COPD/Emphysema
Kidney Disease
Thyroid Disorder
Arthritis
Dementia
Diabetes 1
Diabetes 2
DVT (Blood Clot)
Heart Disease
Depression
Migraines
Father's Type of Cancer?
(Required)
Other
Mother
Mother's Living Age:
Mother's Deceased Age:
Family History (Mother)
Alcoholism
Bipolar Disorder
High Cholesterol
Osteoporosis
Anemia
Cancer
High Blood Pressure
Stroke
Asthma
COPD/Emphysema
Kidney Disease
Thyroid Disorder
Arthritis
Dementia
Diabetes 1
Diabetes 2
DVT (Blood Clot)
Heart Disease
Depression
Migraines
Mother's Type of Cancer?
(Required)
Other
Siblings History
List other medical providers you see on a regular basis (ie. Cardiologist, Mental Health Provider, Dentist, etc.)
As of, today's date, 05/28/2023, I acknowledge having been provided a copy of the Patient HIPAA Acknowledgement and certify that I have read and agree to Total Health Medical Center's (THMC) Payment Policy. I agree and consent to treatment by Total Health Medical Centers which may be either in-person or via telemedicine/virtual visit. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to THMC all money to which I am entitled for medical expenses related to the services performed from time to time by THMC, but not to exceed my indebtedness to THMC. I authorize THMC to release any medical information to my insurance carrier or third party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency. A $35.00 returned check fee will be charged for checks returned due to insufficient funds. I choose to receive communications from THMC by text or e-mail at the number or address stated above, including but not limited to communications about appointments, feedback, treatment, and payment. I understand that such e-mails and texts may not be secure and there is a risk that they may be read by a third party. Comments submitted on surveys may be anonymously shared on the THMC Public Website.
MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to THMC. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services.
HIPAA Authorization For Release of Medical Records
Furthermore, I hereby voluntarily authorize the disclosure of information from my health record as indicated on my release form.
Printed Name of Responsible Party
(Required)
Signature of Responsible Party
(Required)
Reset signature
Signature locked. Reset to sign again
{all_fields}
Acceptance
(Required)
I have reviewed the information I confirm that all the information provided is true and accurate.
Phone
This field is for validation purposes and should be left unchanged.
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