JOHN W. GRACE M.D.,P.A.

CHECK-IN & PAYMENT FORM

PART I

We ask all patients to check-in with us monthly using the first part of this form. If you are seeing a provider for an appointment we ask that you complete the second part of this form as well. This will allow us to better use our time together and also keep your information up to date.

You will see a Green check mark and "Thank You! Your submission has been received." on the screen when this is done successfully. Please make sure you see this before exiting the screen, otherwise your form has not been submitted.

NOTE: FAILURE TO PROPERLY SUBMIT THIS FORM OR COMPLY WITH PAYMENT SCHEDULE BELOW MAY RESULT IN SHORTER SUPPLY OF PRESCRIPTIONS WHILE WE DETERMINE APPROPRIATE ACTION.

Name*

First Name Last Name

Date of Birth*

Date

What is the purpose of this submission?*

I'm preparing for an upcoming appointment. (Parts I and II)I'm checking in between appointments as instructed. (Part I only)I'm am making a payment on my balance. (Part I only)

OVER THE LAST TWO WEEKS I HAVE EXPERIENCED*

	NOT AT ALL(0)	SEVERAL DAYS(1)	> HALF OF DAYS(2)	ALL DAYS(3)
Little interest or pleasure in doing things:
Feeling down, depressed, or hopeless:
Trouble falling or staying asleep/sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead, or of hurting yourself
Self-Destructive Self-Harm Behavior /Thoughts
Using Alcohol and Drugs
Isolating away from friends and family
Poor Sleep/ Wake Cycle
Significant Side Effects to Medication
Not Following Instructions Regarding Treatment
Disturbances in Reality (Hallucinations, Paranoia, Strong obsessions)
Significant anxiety that affects functioning.

MEDICATIONS NEEDED

*NOTE: TRY TO GET THESE REQUESTS IN ABOUT SEVEN DAYS EARLY AS THERE CAN BE MULTIPLE DELAYS (MISCOMMUNICATIONS, SUPPLY, INSURANCE, ETC.) 72 HOURS AFTER YOU SUBMIT THIS FORM, VERIFY THAT THE PRESCRIPTIONS ARE AT THE PHARMACY. IF NOT, CONTACT DR. GRACE ON HIS CELL PHONE.

WHICH MEDICATIONS WOULD YOU NEED REFILLED IN THE NEXT 30 DAYS. List pharmacy NAME, PHONE NUMBER and LOCATION (Ex. Walgreens Crystal River (352)-000-0000) *

HAVE THERE BEEN ANY CHANGES TO YOUR MEDICATIONS FROM OTHER PROVIDERS? IF SO PLEASE LIST ALL MEDICATIONS AND SUPPLEMENTS TAKEN OTHERWISE WRITE "NO"*

REMEMBER

You should be paying for your visit charge plus $20 towards any previous balance every month. Failure to make agreed upon payments may result in decreased prescription duration while we determine whether ongoing care here is affordable for you.

Payment

USDDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING:

1. I am NOT currently a danger to myself or others. Emergencies should be dealt with by contacting 911 or presenting to the nearest emergency room. The Vines in Ocala, Springbrook Hospital, Shands Hospital.

2. I have Dr. Grace's personal cell phone number and will contact him if there is a serious lapse in my care, understanding that he will return my call or deal with my issue within 24 hours.

3. I have read and accept the policies and general instructions of John W. Grace, M.D.

Link here: https://www.johnwgracemdpa.com/instructions-policies

Including the following areas:

POLICIES
- PRIVACY

- BALANCES, LATE CANCELATIONS, AND FEES

- VISIT REQUIREMENTS AND TERMINATION

- THIRD PARTY PAPERWORK

- UNDERSTANDING AND MINIMIZING RISKS OF MEDICATIONS

GENERAL INSTRUCTIONS

HOW TO RELAX BY STRESSING YOURSELF OUT EACH MORNING.

HOW TO BALANCE YOUR IMPROVEMENT

HOW TO SEEK SERENITY MORE THAN EXCITEMENT

HOW TO KEEP A GOOD ROUTINE

HOW TO SEEK SUPPORT FOR GOOD DECISIONS

HOW TO BE MORE MINDFUL

HOW TO TRACK YOUR SYMPTOMS

HOW TO AVOID DESTRUCTIVE IMPULSES

Signature*

Clear

JOHN W. GRACE M.D.,P.A.

CHECK-IN FORM

PART II

If you are seeing a provider for an appointment we ask that you complete the second part of this form as well. This will allow us to better use our time together and also keep your information up to date.

What is your reason for coming to next appt or chief complaint?

Maintenance of current mental health conditionsOther

Email

example@example.com

Phone Number

Please enter a valid phone number.

How would you like us to communicate with you regarding appointment reminders?

You may email, text, or call me with reminders about my appointment.EmailText to the main phone number established with officeLeave a voice mail on the main phone number established with office.

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

PREFERRED LOCATION FOR OBTAINING LABS

QUESTLAB CORPS (WALGREENS)CITRUS MEMORIAL HOSPITALSEVEN RIVERS HOSPITAL

Preferred pharmacy Name & Phone Number

DID YOU IMPLEMENT OUR LAST PLAN? WHAT WAS RESULT?

ANY NEW ISSUES YOU WOULD LIKE TO DISCUSS TODAY?(NEW LABS, CHANGING MEDICAL CONDITIONS, LIFE CHANGES)

WHICH SYMPTOMS DO YOU FEEL HAVE IMPROVED THE MOST SINCE FIRST COMING?

Height

Weight

Recent Blood Pressure & Pulse

List all other Physicians treating you

May we update your other physicians with any recent changes in your care?

YesNoNot Applicable to me