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New Patient Registration Referrals (855) 920-1230
Chesapeake Oncology-Hematology Associates

Telemedicine visits are available for current patients.

New Patient Registration Form

CHESAPEAKE ONCOLOGY - HEMATOLOGY ASSOCIATES, P.A.

NEW PATIENT REGISTRATION FORM

Preferred Office Location*

Patient Information

Insurance Information

CHESAPEAKE ONCOLOGY - HEMATOLOGY ASSOCIATES, P.A.

NEW PATIENT REGISTRATION FORM

In Case of Emergency

Name of friend or relative: Relationship to patient: Home phone no.: Work phone no.:
Living at same address
Not living at same address
Not living at same address

Billing and Medical Information Authorization

If you would like to authorize someone to receive your billing and medical information, please complete the section below.

Name: Phone number: Relationship:

As a courtesy, we may contact you regarding, but not limited to, upcoming appointments or lab results. What is your preferred method of contact?

At Home :

At Work :

Patient/Guardian Signature

he information listed on this sheet is true to the best of my knowledge. I understand that I am responsible for any referrals needed for my care. I understand that I am financially responsible for any balance. I authorize my insurance benefits be paid directly to the physician. I also authorize Chesapeake Oncology - Hematology Associates, P.A. or insurance company to release any information required to process my claims.

CHESAPEAKE ONCOLOGY - HEMATOLOGY ASSOCIATES, P.A.

NEW PATIENT REGISTRATION FORM

Please fill out to your best knowledge; this information will greatly help your doctor

PAST MEDICAL HISTORY: (illnesses, problems, diagnoses; eg: diabetes, cancer, COPD)
Problem Comments, dates, details
1
2
3
4
5
6
7
SURGICAL HISTORY:
1
2
3
4
FAMILY HISTORY: (List medical diagnoses of blood relatives)
Relation Age State of health If deceased, cause of death and age
Mother
Father
Brothers/sisters
SOCIAL HISTORY:

What type of work do you do? (or have done in the past)

Tobacco history

Alcohol/drugs history

CHESAPEAKE ONCOLOGY - HEMATOLOGY ASSOCIATES, P.A.

NEW PATIENT REGISTRATION FORM

Review of Systems

Drenching night sweats*

Recurrent fevers*

Weight loss*

Loss of appetite*

fatigue*

Headache (frequent)*

Eye trouble*

Ear, nose, throat trouble*

Sinus trouble*

Problems swallowing*

Pain with swallowing*

Cough*

Cough with blood*

Shortness of breath*

Chest pains*

Irregular heart beat*

Leg swelling*

Indigestion (GERD)*

Nausea & vomiting*

Vomiting blood*

Jaundice*

Hemorrhoids*

Bleeding from rectum*

Black, tarry stools*

Constipation*

Diarrhea*

Joint pains*

Back pains*

Rash, itch*

Dizziness*

Heaviness of arm or leg*

Depression*

Anxiety*

Insomnia*

Seizures*

Nose bleeds*

Easy bruising*

Enlarged glands (nodes)*

Painful urination*

Frequent urination*

Women Only

Age @ onset of periods

Number of children

Number of pregnancies

Breast feeding

Excessive menstrual bleeding

Mammograms(s)

Men Only

Decreased urine stream

Wake at night to urinate

Wake to urinate # times/night

Decreased erections

Decreased libido

MEDICATIONS

Name Dose per day Reason for drug

Please list any medication allergies:

To download the forms, please use the links below.

Auth to Disclose PHI Medication List Patient History Release of Information Patient Registration

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