New Patient Packet

Fields marked with an asterisk (*) are required.
Name *

Date *

Registration Form

Today's Date

Preferred Name (if different)

Social Security Number

Address *

Email Address *

Marital Status *
MarriedSingleSeparatedDivorcedWidow

Medical Information

Who was your previous medical doctor? *

Doctor Address

Doctor Phone *

Emergency Contact

Name *

Relationship

Address

Phone Number *

Medical History

Please tick this box if it does not apply.

Current Medications

Please tick this box if it does not apply.

Preventive Care

Please tick this box if it does not apply.

Do you have a living will? *

YesNo

Do you have a DNR or file? *

YesNo

Vaccinations

Please tick this box if it does not apply.

Family History *

Smoking *

Do you smoke?
YesNo
Years Smoking

Packs per Day

Alcohol Use *

YesNo

Type
BeerWineLiquor

Drinks per Week

Recreational Drugs *

YesNo
Needle Use
YesNo

Sexual Activity *

YesNo
Number of Partners

Partner Gender
MaleFemale
Birth Control
NoneCondomPill/Patch/IUDVasectomyTubal

Exercise

YesNo
Exercise Type

Duration

Sleep

Hours per Night

Sleep Problems
YesNo

Specialists

Preventive Care – Functional Assessment

Do you need help with any of the following? *

Surgeries & Medical History

Have you had any surgeries?

Medical History

Agreements

AGREEMENT OF OFFICE POLICIES REGARDING PAIN MANAGEMENT.

Dr. Lakshmi Kolli has decided not to treat pain management conditions or prescribe pain medication to patients who take such medications for any type of chronic condition.

This decision is due to the ongoing controversies regarding pain management and the prescribing of pain medications. As you know, we have your best interests and safety in mind. We feel that a pain management specialist will best meet your pain management needs.

We have a list of pain management specialists for you to choose from. Please ask the front desk staff for assistance.

Please call as soon as possible to schedule an appointment with a pain management specialist, as there will be no exceptions to this policy.

By signing this letter, I acknowledge and agree not to request pain medication from this practice. I understand that requesting pain medication may be grounds for immediate termination from this practice.

FINANCIAL POLICY

PATIENT FINANCIAL RESPONSIBILITY AND OFFICE POLICIES AGREEMENT
1. Financial Responsibility: I agree that I am financially responsible for all charges, regardless of my insurance status. I understand that Spring Hill Primary Care will bill my insurance company as a courtesy only.

2. No-Show and Same-Day Cancellation Policy: I agree that there will be a $50 charge for every missed appointment (no-show) or same-day cancellation.

3. Health Insurance Responsibility: I understand that it is my responsibility to verify and understand my health insurance coverage prior to receiving medical services.

4. Authorization to Release Medical Information: I authorize the release of any medical information necessary for insurance processing or reimbursement purposes.

5. Prescription Refills: I understand that prescription refill requests may take up to seven (7) days to process. I agree not to wait until I run out of medication before requesting a refill.

6. Laboratory Results: I understand that laboratory results will not be discussed over the phone.

7. Referral Policy: I understand that referrals will not be provided without an appointment.

Full Name

Signature (Type Name) *