Virtue Medicine Patient Intake Form

Name*

First NameLast Name

Date of Birth*

Date

My Gender Identity is:

My Pronouns are:

examples: She/her, He/him, They/them

I Prefer to be Called (alternate to full name):

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone

Please enter a valid phone number.

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Email

Confirmation Emailexample@example.com

I prefer Virtue Medicine to contact me during our business hours at:*

Cell PhoneHome PhoneWork PhoneEmail

Virtue Medicine uses a scheduling program that provides appointment confirmations by email.

Check here if you DO NOT want appointment confirmations delivered to your email address

With which provider are you scheduled?*

Janeta Tansey, MD, PhDJoAnna Romero Cartaya, PhDArnold Anderson, MD

Is this appointment a part of a Workers' Compensation claim?*

YesNo

Do you have Medicare?*

YesNo

My Primary Care Physician(s):

Other Care Providers:

If I am unable to make decisions because of severe illness, this is name and contact information for the person I prefer to make emergency decisions for me: *

Past medical history and current medical problems (include date/year of diagnosis)

Please list current medications including supplements or vitamins along with dose and dosing schedule

Previous surgeries or injuries

Family medical history (indicate the person's relationship to you and the diagnosis)

Please attach any medical records you would like your provider to review. You may also have medical records faxed to our confidential fax line (319)354-3718

Currently use caffeine?

YesNo

Estimated 8-ounce caffeinated beverage per day

Do you use tobacco currently or have you in the past?

YesNo

Smoked cigarettes from age to .
blank packs per day.

Have you used either of the following type of tobacco?

Do you use alcohol currently or have you in the past?

YesNo

Current estimated drinks per week .

Check if you've had the following alcohol complications:

History of alcohol use:

Do you use drugs or other substances currently or have you in the past?

YesNo

Type(s) of drug or substance use, whether for health benefit or recreation, and history of use:

Check if you've had the following drug complications:

Please list allergies or intolerances of medications, latex, dyes, foods, or other:

Describe your typical physical activities/exercise:

Describe your typical daily diet:

Virtue Medicine Privacy Policies are available here and at our website VirtueMedicine.com

This agreement is between Dr. blanks, whose principal place of business is 221 E. College St. Ste. 212, Iowa City, IA 52240 and:

Beneficiary (your name): blank
Who Resides at:   Street Address
Address Line 2
City   State   Zip
Medicare ID #:

The beneficiary is a Medicare Part B participant seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The doctor has informed Beneficiary or his/her legal representative that the doctor has opted out of the Medicare program. The doctor is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.
Beneficiary or his/her legal representative agrees, understands and expressly acknowledges the following:

_____ Beneficiary or his/her legal representative accepts full responsibility for payment of the doctor’s charge for all services furnished by the doctor.

_____ Beneficiary or his/her legal representative understands that Medicare limits do not apply to what the doctor may charge for items or services furnished by the doctor.

_____ Beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask the doctor to submit a claim to Medicare.

_____ Beneficiary or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the doctor that
would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

_____ Beneficiary or his/her legal representative enters into this contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from doctors and practitioners who have not opted out of Medicare, and the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other doctors or practitioners who have not opted out.

_____ Beneficiary or his/her legal representative understands that Medicare Supplement Insurance (Medigap) plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.

          Beneficiary or his/her legal representative acknowledges that the beneficiary is not currently in an emergency or urgent health care situation.

          Beneficiary or his/her legal representative acknowledges that a copy of this contract has been made available.

I have had opportunity to discuss all aspects of this agreement with my health care provider. My signature below demonstrates that I have read, understand and agree to abide by the terms of this agreement for the duration of my care with my provider and during the period that she is opted out of the Medicare program.

Executed by:

Signature for Medicare Agreement*      Date*

Signature*

Date