Medical Physicians Group PLLC

Medical Physicians Group PLLC

7855 Arygle Forest Blvd #504, Jacksonville FL 32244

12443 San Jose Blvd Suite 403, Jacksonville FL 32223

531 South 6 St. Suite #1, Macclenny FL 32063

https://medicalphysiciansgroup.com

admin@medicalphysiciansgroup.com

Phone # 863-874-0898

Fax # 833-728-7733
Health Insurance Portability and Accountability Act (HIPPA) Acknowledgement

I have received the HIPAA information. I understand that Medical Physicians Group PLLC and Dr. Leung will make all attempts to protect patient’s medical information.
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Medical Physicians Group PLLC

Cancellation Policy and Payment Policy

I understand that there is a $25 for any cancellation, rescheduleing, and/or "No Show" less than 24 hours prior to the appointment. I understand if insurance does not pay for your benefits and/or if your benefits have expired, then it is the patient’s responsibility to pay for the office visit and/or the procedure, vaccination, and/or any medical services rendered.
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Allergy and Drug Information- New Patient
Do you currently have any known allergies (drug, food, environment) and if so please include the reaction?

YesNo
If so, please list all known allergies (food allergies included) and include the reaction to it
When was the last time you received a flu shot?
If you are 50 years old or above, when was the last time you had colonoscopy done?
If you have diabetes or hypertension, when was the last time you were tested for diabetes/hypertension related kidney problems?
If you have diabetes or hypertension, when was the last time you had an eye exam from an eye doctor?
For females, when was your last menstrual period?
For females, how many days is your menstrual cycle?
For females, are you in Menopause?
For females, is there a chance that you can be pregnant?

YesNo
For females, do you take birth control pills?

YesNo
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For females, if you are 21 years old or above, when was the last time you had a pap smear done?
For females, if you are 50 years old or above, when was the last time you had a mammogram done?
Please list all medications taken. Include name of medication (including strength), physician’s name who prescribed the medication, date of last refill, and how often you take this medication. This includes prescription medication, medical supplements (both physician and non-prescription prescribed), and any recreational drugs.
By completing the above information, you acknowledge the following: All

prescribed and non-prescribed medications taken, including their current dosages and

strengths, have been truthfully stated on this form. Should our physician prescribe

medication which could cause a reaction with any unknown substances at the time of prescription, the patient agrees to hold harmless said physician.

If there is any change in medication taken from another provider, or another provider issues a new or change of prescription, it is up to the patient to notify us to update this change in his/her medical records and advise patient regarding any possible drug
Signature of Patient or Patient's Representative:

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Reason for Today's Visit:
Please Circle and Elaborate if You Have Seen a Physician or Have Been Diagnosed with Any of the Following:
Arthritis
Blurry Vision
Cancer
Chest Pain
Circulation Issues
Diabetes
Digestive Issues
Dizziness
Fatigue
Female Health/Gynecological
Heart Conditions
High Cholesterol
High Blood Pressure
Hormonal Issues
Incontinence
Insomnia
Low Blood Pressure
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Male Health
Mental Health Conditions (insomnia, anxiety, depression, etc.)
Migraines
Pain (describe location)
Paralysis
Respiratory Conditions (including Asthma, COPD, and Shortness of Breath)
Substance Abuse/Chemical Dependency
Do you currently use any medical devices? This includes assistive devices used as needed or prescribed regular use equipment. Some examples can include a nebulizer, CPAP machine, walker/cane, oxygen system, etc. If so, please list below:
I hereby attest to the best of my knowledge, all above statements regarding my previous known health conditions have been disclosed and answered truthfully.
Patient's Signature

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Surgical History
Please list all Surgeries (both Inpatient and Outpatient), and Their Dates?
Social History
Do you use tobacco products? If so, how much packs per day and for how many years?
Do you drink alcohol? If so, how much do you drink and how often?
Please list all illicit drugs use including marijuana.
Family History
What medical conditions does your mother have? What medications is she using? Is she alive?
What medical conditions does your father have? What medications is he using? Is he alive?
Please list your brother(s) and sisters(s) and their medical conditions? Are they alive?
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Insurance Information
Primary Insurance Company's Name
Group Number:
Policy Number:
Policy Holder's Name
Relation to Patient:
Phon Number:
Policyholder's Email:
example@example.com
Policyholder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder's Place of Employment:
Secondary Insurance Company Name:
Group Number:
Policy Number:
Policyholder's Name:
I hereby attest that all insurance information is truthful and current. If insurance information is unable to be verified at time of appointment, or a company rejects any claim, it is up to the patient or patient’ representative to pay via cash and perform a self-claim filed with their own insurance company for self-reimbursement.
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