CONSENT FOR CHARITY CARE I, , acknowledge that the physicians and staff of Christ Clinic are volunteer health care providers and are not administering care for or in expectation of compensation. I also understand that as volunteer health care providers, the physicians and staff of Christ Clinic are immune from any civil liability for any act or omission resulting in death, damage or injury as the volunteer acts are in good faith and in the scope of his/her duties within the organization in providing the health care services.

PATIENT/GUARDIAN SIGNATURE

DATE

ACKNOWLEDGEMENTS I have received and reviewed the following from Christ Clinic (please check): Patients Rights & Responsibilities Notice of Privacy Rights By signing this, I am fully aware of both documents and agree to the information provided in each.

PATIENT/GUARDIAN SIGNATURE

DATE

DESIGNATION TO RELEASE CONFIDENTIAL MEDICAL INFORMATION Some patients prefer that other individuals, especially family members, be allowed access to their medical information. In accordance with Federal government privacy rules, a written release is required to allow another person access to your medical records. This release grants permission to individual(s) listed below to: make or confirm appointments, have access to x-ray and laboratory findings, pick up medication, be made aware of your diagnosis, prognosis, and treatment plans, and serve as your emergency contact. I do NOT give permission for anyone else to be contacted other than myself I give permission to contact the following people:

Name

Telephone

Relation to Patient

Please mark your selection pick up medications make appointments receive medical information pick up medications make appointments receive medical information

Answering Machine Messages There may be times when our office is not able to reach you by telephone. With your permission, we would like to be able to leave messages on your home answering machine or voice mail. Home voice mail?

Yes

No

Cell phone voice mail?

Yes

No

Messages will not be left on answering machines or voice mail if the recorded greeting does not include confirmation of your name or phone number.

PATIENT/GUARDIAN SIGNATURE Revised 9/13

DATE

PATIENT INFORMATION Name ___________________________________________________________ Date of Birth __________________________ Age ____________ Address __________________________________________________________________________________________________________________ Street Apt. City State Zip Code County Home Phone ___________________________________________________ Cell Phone ________________________________________________ Guardian 1

________________________________________ Phone ____________________________ Relationship _________________

Guardian 2

________________________________________ Phone ____________________________ Relationship _________________

Emergency Contact ____________________________________ Phone ____________________________ Relationship _________________

Social Security No. _________________________________________

□Male □Single □Hispanic/Latino □White □Asian

□Female Marital Status: □Married □Divorced □Widowed □Separated Ethnicity: □Non-Hispanic/Latino □Unreported/Refused Race: □Black/African-Amer. □Amer. Indian/Alaska Native □Native Hawaiian/Pacific Islander □More than one race □Unreported/Refused Are you? U.S. Citizen □Yes □No U.S. Resident □Yes □No Patient Employment Status: □Full Time □Part Time □Unemployed □Disabled □Student □Not in Labor Force Primary Language: □English □Spanish □English & Spanish □English & Other □Other________________________ Gender:

WERE YOU REFERRED BY:

□ Christus St. Catherine Hospital

□ Memorial Herman Katy Hospital

□ Methodist Hospital West

□ Texas Children’s Hospital

Or how did you find out about Christ Clinic? ______________________________________________________________________________________

MONTHLY HOUSEHOLD INCOME AND HOUSING INFORMATION Total Dollars Received Each Month for Entire Household (Source of Income) Wages/Salary

$___________________

Social Security

$___________________

Unemployment

$___________________

Child Support

$___________________

Workmen’s Comp

$___________________

Other

$___________________

Disability

$___________________

TOTAL Monthly HOUSEHOLD Income

Housing:

□Own

□Rent

□Stay with friend or family

□Shelter

Total number of ADULTS living in the household

_________________

Total number of CHILDREN under 18 years in the household

_________________

$_________________________________

□Other _____________________________________

PATIENT COVERAGE INFORMATION (Do you have or receive?) Insurance: Medicare: Medicaid: CHIP: Gold Card: Food Stamps:

□Yes □Yes □Yes □Yes □Yes □Yes

□No □No □No □No □No □No

If yes, name of insurance company ____________________________________________________________ If no, must show denial letter If no, must show denial letter If no, must show denial letter

I have read the information provided and answered accordingly. My responses are true and accurate to the best of my knowledge. ____________________________________________ Patient /Guardian Signature Reviewed by Front Desk Volunteer/Staff ________

____________________________________________ Patient/Guardian Printed Name Revised 8/13

______________________ Date See Other Side

PATIENT REGISTRATION

Date (Fecha)_________________________________

Name __________________________________________________________________ Date of Birth ________________________ Age _________ (Nombre)

(Fecha de Nacimiento)

Home Phone ____________________________________________________ Cell Phone (Teléfono de Casa)

(Edad)

________ _____

________

(Teléfono Celular)

GENERAL MEDICAL INFORMATION Describe current medical problem/reason for visit (Describe problema médico actual / razón de la visita)

Allergies to Medications (Alergias a Medicamentos)

Females only: Are you pregnant, planning a pregnancy or nursing a child?

□Yes □No

□Yes □No

□Cigarettes □Cigar □Pipe No. of years? ________ How much _________________ Do you regularly drink alcohol? □Yes □No How much? __________________________________ Do you regularly drink coffee? □Yes □No How much? ________________________________ Do you use street drugs of any kind? □Yes □No What kind? _____________________ Have you ever shared needles? □Yes □No Are you under a lot of stress/pressure in your life? □Yes □No (Sólo las mujeres: ¿Está embarazada, planea quedarse embarazada o amamantando a un niño?)

Do you smoke?

If yes:

(¿Usted fuma?)

(No. de años)

(cantidad)

(¿Bebe alcohol regularmente?)

(cantidad)

(¿Bebe café regularmente?)

(cantidad)

(¿Usted utiliza drogas ilegales de cualquier tipo?)

(¿qué tipo?)

(¿Alguna vez has compartido agujas?)

(¿Se siente bajo mucha tensión / presión en su vida?)

If yes, please describe: (Por favor describa)

_

________________________________________________

PERSONAL MEDICAL HISTORY Have you ever had or do you currently have any of the following (check all that apply): (¿Alguna vez ha tenido o tiene actualmente alguna de las siguientes?) Chest pain/pressure/tightening (dolor en el pecho / presión) Asthma (asma) Kidney disease (enfermedad renal) Hypertension (hipertensión) Dizzy spells (mareos) Shortness of breath (falta de aire) Heart attack (ataque del corazón) Cancer (cáncer) TB/lung disorder (tb / trastorno pulmonar) Stroke (derrame cerebral) Diabetes Ulcers (úlceras) Headache (dolor de cabeza) Arthritis (artritis) Skin disorders (trastornos de la piel) Staff infection (MRSA)infección por estafilococo meticilina (SARM ) Difficulty hearing (dificultad para oír) Hepatitis Allergies or Eczema (alergias o eczema) Glaucoma Cataracts (cataratas) Depression (depresión) Memory loss(Pérdida de la memoria) Digestive problems (problemas digestivos) Blood in stool (sangre en las heces) Hemorrhoids (hemorroides) HIV/Hepatitis C/AIDS (VIH / hepatitis c / sida) Frequent urinary infections (frecuentes infecciones urinarias) Other (Otro) ________________________________________________________

□ □ □ □ □ □ □ □ □ □

□ □ □ □ □ □ □ □ □ □

□ □ □ □ □ □ □ □ □

SURGICAL HISTORY / HOSPITALIZATION

FAMILY HISTORY: check all that apply (Historia Familiar)_

(ANTECEDENTES QUIRÚRGICOS / HOSPITALIZACIÓN)

Father

Mother

Year and procedure: (año y procedimiento)

□ □ □ □ □

(Padre)

_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

OTHER MEDICAL INFORMATION

□ □ □ □ □

(Madre)

High Blood Pressure (hipertensión) Heart Attack/Stroke (ataque del corazón/ derrame cerebral) Diabetes Cancer (cancer) Asthma (asma)

Father’s Mother’s Parents Parents Siblings Children (Abuelos (Abuelos Paternos) Maternos) (Hermanos) (Hijos)

□ □ □ □ □

□ □ □ □ □

□ □ □ □ □

□ □ □ □ □

(OTRA INFORMACIÓN MEDICA)

Provide any additional information that would be important in treating you: (Provea información adicional que sea importante para su cuidado medico.) _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

________________________________________________________________________________ Patient Signature (if 18 years of age or older)

Date (Fecha)

(Firma del Paciente) (si es mayor de edad 18)

__________________________________________________________________________________________________________________________________________

Signature of Parent or Guardian Revised 8/13

(Firma de Padre o Guardian)

Relationship

(Relación)

Date (Fecha) See Other Side (Vea el otro lado)