Online Patient Forms

PATIENT INFORMATION
Patient Name:*
First Last
Today's Date:
Date Format: MM slash DD slash YYYY
Contact Phone Numbers:*
Daytime Phone: Cell Phone:
Preferred Phone:*
- Daytime phone
- Cell phone
Email Address:*
Address:*
Street Address City State ZIP Code
Date of Birth:*
Sex:*
- Male
- Female
Marital Staus:*
- Married
- Single
- Divorced
- Widowed

Please fill out your emergency contact below.
Emergency Contact:*
Emergency Contact's Relationship to Patient:*
Emergency Contact's Phone:*

Surface Clinical reserves the right to charge a fee for any scheduled visits that are:

1. Cancelled with less than 24 hours notice

2. Are missed without calling to cancel ( no show)

Cancellation Fee schedule: New Patient $50.00; Established Patient: $35.00
Patient / Parent or Guardian Signature:*

ONLINE PHOTOGRAHPY CONSENT FORM
I, the undersigned, hereby authorize Surface Clinical to take my pre-photos for planning purposes, medical evaluation, surgical or other procedures and subsequent treatment.Your photos will not be used in any publication or on the Internet without your notification and a separate form signed by you. I herein relinquish any right, title, or interest in such photographs and I understand that my identity will not be revealed by the pictures or by the descriptive texts accompanying them.

Person Photographed:
First and Last Name:*
Email*
Phone*
Date*
Date Format: MM slash DD slash YYYY
Signature*

ONLINE HIPPA CONSENT FORM
SURFACE CLINICAL NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
Protecting your privacy: Protecting your privacy and your medical information is at the core of our business. We recognize our obligation to keep your information secure and confidential whether on paper or the Internet. At Surface Clinical (hereafter referred to as "the Practice"), privacy is one of our highest priorities.
Keeping your information: Keeping the medical and health information we have about you secure is one of our most important responsibilities. We value your trust and handle your information with care. Our employees access information about you only when necessary to provide treatment, verify eligibility, obtain authorization, process claims and otherwise meet your needs. We may also access information about you when considering a request from you or when exercising our rights under the law or any agreement with you. We safeguard information during all business practices according to established security standards and procedures, and we continually assess new technology for protecting information. Our employees are trained to understand and comply with these information principles.
Working to meet your needs through information: ln the course of doing business, we collect and use various types of information, like name and addre􀅋 and claims information. We use this information to provide service to you, to process your claims and to bring you health information that might be of interest to you.
Keeping information accurate: Keeping your health information accurate and up-to-date is very important If you believe the health information we have about you is incomplete, inaccurate or not current, please call or write us at the telephone number or address listed below. We take appropriate action to correct any erroneous information as quickly as possible through a standard set of practices and procedures.
How - and why- information is shared: We limit who receives information and what type of information is shared. Sharing information within the Practice. We share information within our office to deliver you the health care services and the related information and education programs in your plan.
Sharing information with companies that work with us. To help us offer you our services, we may share information with companies that work for us, such as claim processing and mailing companies that deliver health education and information directly to you. These companies act on our behalf and are obligated to keep the information that we provide them confidential.
Other. Patient-specific personally identifiable data is released only when required to provide a service for you and only to those with a need to know, or with your consent. Data is released with the condition that the person receiving the data will not release it further, unless you give permission.
If we receive a subpoena or similar legal process demanding release of any information about you, we will attempt to notify you ( unless we are prohibited from doing so). Except as required by law or as described above, we do not share information with other parties, including government agencies.
The Practice does not share any customer information with third-party marketers who offer their products and services to our patients.
Count on our commitment to your privacy: You can count on us to keep you informed about how we protect your privacy and limit the sharing of information you provide to us-whether it's at our office, over the phone or through the Internet.
First and Last Name:*
Email*
Phone*
Date*
Date Format: MM slash DD slash YYYY
Signature*

Step 1 of 6

PATIENT INFORMATION

HEALTH HISTORY

ONLINE PHOTOGRAHPY CONSENT FORM

ONLINE HIPPA CONSENT FORM

First	Last

Daytime Phone:	Cell Phone:

Age	Weight	Height

Medication Name	Reason for Taking	Dosage/Frequency