new-patient-packet

Child's name
D.O.B.
Welcome to our practice. We are dedicated to providing quality personal health care to each of our patients. In order to facilitate your first visit, please complete paperwork prior to your scheduled appointment. Due to the additional time our staff requires to prepare your chart for your first visit, we ask that you arrive 30 minutes prior to your scheduled appointment. Failure to arrive within this time will result in rescheduling of your appointment. Please have your completed paper work, your child's insurance card and picture identification available when you arrive for your appointment.

There will be a $50.00 charge for all appointments that are not kept or are cancelled with less than 24 hours notice.

AS a courtesy to our patients, we will verify your insurance benefits prior to or on your first visit. This will indicate covered services and your financial responsibility. Co-payments or coinsurance's are due at the time services are rendered. Failure to provide you co-payments upon each visit will result in rescheduling your appointment. For your convenience we accept cash, personal checks, MasterCard, Visa, Discover, and American Express. A $35.00 charge will be applied to all returned checks.

Our physician cannot assume any responsibility for you medical care until you have become an established patient. Therefore, no prescriptions, diagnostic testing or treatment can be given at your initial visit.

Thank you for choosing our practice to meet your medical needs. Our goal is to provide you with the best medical care available in a relaxed and warm atmosphere.
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Please answer all questions fully
7635 ASHLEY PARK CT SUITE 501
ORLANDO, FL 32835-6196
Account Number
Phone: (407)297-0080 Ext. Fax: (407)295-3080
Ext. Fax
Name (Last, First, MI)
Social Security
Age
Birthdate

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Sex
Race
Address

Mailing Address

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City State

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Employer
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Responsible Party Name (Last, First ,MI)
Name (Last, First ,MI)
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Address

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City State

Zipcode
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Employer
City
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Primary Provider
Referring Provider
Referring Address
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Primary Insurance Company
Subscriber's Name, Birthdate, SSN

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Relationship
Policy Number/Group#
Copay
Second Insurance Company
Subscriber's Name, Birthdate, SSN

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Policy Number/Group#
Copay
Third Insurance Company
Subscriber's Name, Birthdate, SSN

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Relationship
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Secondary Phone Number
Please List Additional Medical Information
I certify the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare), for purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I ACKNOWLEDGE THAT INTEREST OR A FEE, AT THE PROVIDER'S CURRENT RATE, MAY BE CHARGED on all balances owing to the provider that are past due.

I permit a copy of this release to be used in place of the original.
(Signature of insured or authorized person, patient or parent if minor)

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For all Your Growing Needsiundermere Pediatrics

You must notify us of any changes in your insurance

This is the only way to ensure all lab tests and claims are filed/or billed correctly. It is the parent's responsibility to be sure the correct information is in your child's chart. Any charges accrued due to incorrect information will be bill to you, the parent.
Patient Name
Ins Company Name
Ins Company ID#
Laboratory Name
The operating hours of Windermere Pediatrics DO NOT include Saturdays. If you feel your child has an urgent medical need on a Saturday, you may contact our office and arrange to have your child seen by the physician on call.

It is important for you to note that an additional after hour charge of $30.00 is billed to you child's account for this service.

Some insurance carriers may deny this claim as non-urgent or not covered through your plan.

If your child is seen in our office on Saturday, you will be financially responsible for the additional $30.00 charge.

Please sign your acknowledgement and acceptance below.
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windermere For all Your Needs! Pediatries

FOR USE AND DISCLOSURE OF PROTECTED HEALTHINFORMATION

In connection with the medical services my child is receiving from Windermere Pediatrics, I consent to and authorize the physicians and their staff to use and disclose any and all Protected Health Information (PHI) necessary to carry out treatment, Payment and healthcare operations (TPO) related to my child's medical care. I understand the Notice of Privacy Practices is available from the receptionist and that it offers a more complete description of uses and disclosures. This of ffice reserves the right to review and change our Notice of Privacy Practices at any time. Windermere Pediatrics may call my home or office and leave a message in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my child's healthcare. I have the right to request that this practice restricts how they use of disclose my protected health information (PHI) to carry out treatment, payment, and healthcare options (TPO However this office is not required to agree to my request restrictions but if they do the office is bound by this agreement. By signing this form I consent to the use and disclosure of my child's PHI to carry out treatment, payment and health care operations (TPO This consent may be revoked by submitting a request in writing. If I decline to sign this consent, this practice may decline to provide my treatment.
Printed Patient Name
Printed Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian

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windermore Pect Satries Welcome! Please take a few moments to tell us how you heard about Windermere Pediatrics.

Patient Name
windermore Pect Satries Welcome! Please take a few moments to tell us how you heard about Windermere Pediatrics.

Friend/Family
For all Your Growing Needs!

windermore Pect Satries Welcome! Please take a few moments to tell us how you heard about Windermere Pediatrics.
For all Your Growing Needs!

Windermere Pediatrics Brochure or other promotional item
For all
Welcome!
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My Doctor
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My Doctor

Our Website
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Our Website

Health Central Other
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Playground Tu Revista Hospital Florida Hospital Arnold Palmer/Winnie Palmer Magazine Ad South West Bulletin Other
Other
Ginny Guyton, MD Marc Feldman, MD Denise Serafin, MD

WINDERMERE PEDIATRICS 7635 ASHLEY PARK CT. SUITE 501 ORLANDO, FL. 32835

Amber Eastwood ARNP Larissa Negron, MD Maryann Dunn, ARNP
Amber
Telephone #: 407-297-0080
Fax #
I hereby authorize the personal health information pertaining to my child to be obtained or released. I understand that these records may contain information including psychological, psychiatric, treatment.alcoholic substance abuse, HIV/AIDS results, testing and/or other information regarding diagnosis and
MEDICAL RECORDS RELEASE
Patient's Name: Patient's Date of Birth:
Patient's Name
Patient's Date of Birth

Month Day Year
Date
OBTAIN RECORDS FROM:
Windermere Pediatrics will
Address: City: Phone #: Fax #
From
RELEASE RECORDS TO:
Address

Address

Street Address Line 2

City
Address
To
Fax #
City: Phone #
City
All Medical Records
Other
Lab Results
Pt. History/Physical; Last 3 Office Notes; Growth Chart; Immunization Record
Reason for records: Please check the specific records needed: All Medical Records Lab ResultsPt. History/Physical; Last 3 Office Notes; Growth Chart; Immunization Record Other
Fax #
Reason for records
Signature of Parent/Guardian

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Initial History Questionnaire
Name
ID NUMBER
FORM COMPLETED BY
DATE COMPLETED

Month Day Year
Date
BIRTH DATE

Month Day Year
Date
Please list all those living in the child's home.
Are there siblings not listed? If so, please list their names and ages and where they live.
If mother and father are not living together or if child does not live with parents, what is the child's custody status?
If one or both parents are not living in the home, how often does he/she see the parent/parents not in the home?

Cesarean?
Birth weight

If early, how many weeks' gestation? Was the baby born at term?
Birth weight
Was the delivery

Vaginal?
Was the delivery

Bottle?
Was the baby born at term?
Vaginal?

Did your baby have any problems right after birth? Yes No Explain If cesarean, why?
Early?
Late?
If early, how many weeks' gestation?
If cesarean, why?
Explain
Was initial feeding

Breast?
Bottle?

Yes No Drink alcohol Did your baby go home with mother from the hospital? Yes No Explain Was initial feeding
During pregnancy, did mother Smoke Yes No Use drugs or medications What

Yes No
Yes No

During pregnancy, did mother Smoke Yes No Use drugs or medications What Did mother have any illness or problem with her pregnancy? Yes No Explain
Explain
What
When
Do you consider your child to be in good health?

Does your child have any serious illness or medical condition?
Explain

Yes No
Explain
Has your child had serious injuries or accidents?
Explain

Yes No
Explain
Has your child had any surgery?
Explain

Yes No
Explain
Has your child ever been hospitalized?
Explain

Yes No
Explain
Is your child allergic to any medicines or drugs?
Explain

Yes No
Explain
Explain

Yes No
Explain
Are you concerned about your child's physical development?
Are you concerned about your child's mental or emotional development? Are you concerned about your child's attention span?

Yes No
Are you concerned about your child's mental or emotional development? Are you concerned about your child's attention span?

Yes No
Explain

Yes No
Explain
Explain
Explain
How is his/her behavior in school?
Is he/she in special or resource classes?
How is he/she doing in academic subjects?
Has he/she failed or repeated a grade in school?
American Academy of Pediatrics DEDICATED in THE HEALTH OF ALL CHILDREN
Initial History Questionnaire
Have any family members had the following:
Deafness

Yes Who No
Who
Comments
Nasal allergies

Yes Who No
Who
Comments
Asthma

Yes Who No
Who
Comments
Tuberculosis

Yes Who No
Who
Comments
Heart disease (before 50 years old)

Yes Who No
Who
Comments
High blood pressure (before 50 years old)

Yes Who No
Who
Comments
High cholesterol

Yes Who No
Who
Comments
Anemia

Yes NoWho
Who
Comments
Bleeding disorder

Yes Who No
Who
Comments
Liver disease

Yes Who No
Who
Comments
Kidney disease

Yes Who No
Who
Comments
Diabetes (before 50 years old)

Yes NoWho
Who
Comments
Bed-wetting (after 10 years old)

Yes Who No
Who
Comments
Epilepsy or convulsions

Yes Who No
Who
Comments
Alcohol abuse

Yes Who No
Who
Comments
Drug abuse

Yes Who No
Who
Comments
Mental illness

Yes Who No
Who
Comments
Intellectual disability

Yes Who No
Who
Comments
Immune problems, HIV, or AIDS

Yes Who No
Who
Comments
Additional family history
Does your child have, or has he/she ever had:
Chickenpox

Yes When No
When
Frequent ear infections

Yes NoExplain
Explain
Problems with ears or hearing

NoExplain Yes
Explain
Nasal allergies

NoExplain Yes
Explain
Problems with eyes or vision

Yes NoExplain
Explain
Asthma, bronchitis, bronchiolitis, or pneumonia

Yes NoExplain
Explain
Any heart problem or heart murmur

Yes NoExplain
Explain
Anemia or bleeding problem

Yes NoExplain
Explain
Blood transfusion

Yes NoExplain
Explain
Frequent abdominal pain

Yes NoExplain
Explain
Constipation requiring doctor visits

Yes NoExplain
Explain
Bladder or kidney infection

Yes NoExplain
Explain
Bed-wetting (after 5 years old)

Yes NoExplain
Explain
(For girls) Has she started her menstrual periods?

Yes NoWhen
When
(For girls) Are there problems with her periods?

Yes NoExplain
Explain
Any chronic or recurrent skin problem (acne, eczema, etc)

NoExplain Yes
NoExplain

NoExplain Yes
Explain
Frequent headaches

NoExplain Yes
Explain
Convulsions or other neurologic problem

NoExplain Yes
Explain
Diabetes

NoExplain Yes
Explain
Thyroid or other endocrine problem
Explain
Any other significant problem

Yes NoExplain
Explain
Use of alcohol or drugs

Yes NoExplain
Explain
Should be Empty:

7635 ASHLEY PARK CT SUITE 501

ORLANDO, FL 32835-6196

MEDICAL RECORDS RELEASE

OBTAIN RECORDS FROM:

RELEASE RECORDS TO:

Initial History Questionnaire

ID NUMBER

FORM COMPLETED BY

American Academy of Pediatrics DEDICATED in THE HEALTH OF ALL CHILDREN

Initial History Questionnaire