new patient intake form - HIE Networks

Tallahassee Pulmonary Clinic, P.A. Pulmonary Medicine – Critical Care 1401 Centerville Road, Suite G-02 Tallahassee, FL 32308 (850)878-8714 (850)878-5138 FAX (850)878-8305 John S. Thabes - M.D. Carlos E. Campo - M.D. 2626 Care Drive, Suite 101 Tallahassee, FL 32308 (850) 877-1528 FAX (850) 671-3444

Clifton J. Bailey - M.D. J. Daniel Davis - M.D. David Y. Huang - M.D. F. Ray Dolly - M.D. Praful B. Patel - M.D.

NEW PATIENT INTAKE FORM For referring Physicians, PLEASE complete the following information then fax back to 850-878-0552 with the diagnosis appropriate records. Once received, we will call the patient with appointment. Before we are

able to schedule your patients, we must have all records pertaining to the referring diagnosis. (ie: notes, CXR/CT reports overnight Pulse Ox, PFT’s) THANK YOU.

Patient Name: _____________________________________ DOB: ______________________________ Address: _____________________________________ ZIP CODE: _______________________________ Home Phone: __________________ Work #: __________________ Cell #: ____________________ Referring Physician: _______________________ Contact Person: ________________________ Phone #: ___________________ Back Line #: ___________________ Fax: _______________________ Diagnosis: _______________________________________________________________ Insurance: ____________________________ Policy #: ________________ Referral #: _______________ Chest X-Ray location: __________________ CT Location: __________________

Patient needs to be seen: 1 month

Routine

Urgent

FOR OUR OFFICE ONLY:

Date of Appt: ______________________ Time: __________ Physician: ______________________ Patient information sheets sent on: ________________________________________________________ Canceled / Rescheduled by: ____________________________ OR ____________________________ M.D. Office (name & date) Patient & Date REASON FOR CANCELLATION: ________________________________________________________