Professional legal forms

Intake form reflexology Client Intake Form Reflexology Personal Information: Name Primary Phone Address City/State/Zip Email Date of Birth Occupation Emergency Contact Phone The following information will be used to help

Functional medicine adult new... AMY MYERS, MD Austin UltraHealth Westlake Medical Center 5656 Bee Cave Road Suite D-203 Austin, Texas 78746 Phone: 512-383-5343 Fax: 512-721-0348 FUNCTIONAL MEDICINE ADULT NEW PATIENT INTAKE FORMS THESE

Chiropractic auto accident int... Christensen Chiropractic New Patient Intake Form. Patient Data. Date. . Title : (Check one). Mr. Mrs. Ms. Miss Dr. Other . First Name ...

Katrinas theraspa chair massag... Katrinas TheraSpa Chair Massage Client Intake Form Name: Address: City State Zip Phone: Email Are you interested in receiving our client newsletter? yes no Are you experiencing any of the following:

Moasis therapeutic massage cli... Moasis Therapeutic Massage Client Intake Form Personal Information: Name Date of First Visit Cell Phone Home Phone Work Phone Address City/State/Zip Email Date of Birth Occupation Emergency Contact

Worker s compensation intake f... Clear FormPATIENT INFORMATIONEMAIL ADDRESS: First Name:Last Name:Middle Initial:Address: Birth date:City: /Home Phone: (/ )Age:MaleFemaleCell Phone (Married)SingleOtherDate:/State:Zip:S.S. #:/ Spouses

Bear cubs preschool intake for... Bear Cubs Preschool Intake Form 2010 2011 1. Child s Information Child s Legal Name Name child goes by Birthdate Gender Male/Female Address Street Mailing Town, Zip Primary Home Language Does Child

Gynecology intake form GYNECOLOGY INTAKE FORM DATE: / / NAME: AGE: BIRTH DATE: / / ADDRESS: CITY STATE/ZIP HOME #: CELL #: WORK #: PRIMARY CARE MD: HEIGHT: An

Blank mri medical forms Signatures are NOT required for Accreditation Renewal or Change in Accreditation Category. 40. Date VS Form 1-36A OCT 2012 Instructions for Completing VS Form 1-36A National Veterinary Accreditation Program NVAP Application. Block 1. PRIVACY ACT NOTICE General This information is provided pursuant to Public Law 95-3579 Privacy Act of 1974 December 31 1974 for individuals completing the VS 1-36A. According to the Paperwork Reduction Act of 1995 an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0297. The time required to complete this collection of information is estimated to average. 5 hours per response including the time for reviewing instructions searching existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information* OMB Approved 0579-0297 Exp* 11/2012 1. Initial Accreditation 2. Authorization in a new State State UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES License Number 3. Change Accreditation Category Block 15 or 16 4. Contact Information Change 5. Accreditation Renewal 6. Post-Revocation Re-Accreditation NATIONAL VETERINARY ACCREDITATION PROGRAM APPLICATION FORM 7. Name of Veterinarian Last First M Suffix 9. Other Names Used e*g* Maiden Name Check if your name has changed* 10. Date of Birth 8. Six-Digit National Accreditation Number 11. School of Veterinary Medicine 12. Year Graduated 14. Are you interested in participating in State or Federal agricultural emergency response efforts 13. State where First Orientation Completed Yes No ACCREDITATION CATEGORY SELECTION select only one Block 15 OR 16 Category I animals includes canines felines amphibians/reptiles furbearing animals laboratory animals rodents and non-human primates Refer to Explanation of Codes Page Practice Code s select up to two Species Code s 17 rodents select up to four this does not limit the number of Category I species upon which you may perform accredited duties Primary Medical Discipline Employment Type list up to two list up to four this does not limit the number of species upon which you may perform accredited duties CONTACT INFORMATION 24. Name of Business 17. Home Mailing Address 25. Business Mailing Address 18. City 19. State 20. ZIP Code 26. City 27. State 21. County of Home Mailing Address 29. County of Business Mailing Address 22. Home Phone 30. Business Phone 23. Email Address 31. Business Cell Phone 32. Business FAX Number 33. Please mark the Contact Information USDA may make available to the public Module Number Home Business None select at least one Enter the module numbers not names of the APHIS approved supplemental training modules you have completed* Category I veterinarians three modules Category II veterinarians six modules. Course Type Date Module Completed By signing in block 37 I certify that the information contained in this form is true and correct to the best of my knowledge.

Padi medical form fillable Participant Record (Confidential Information) Please read carefully before signing. This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct

Auburn medical form 2012 DIRECTIONS FOR THE MEDICAL FORM Both pages must be completely filled out. 1. Fill out the form COMPLETELY before turning it in or it will be returned to you. An incomplete form may keep students from

Lac usc form DEPARTMENT OF HEALTH SERVICES COUNTY OF LOS ANGELES AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION Last Name First HEREBY AUTHORIZES LAC USC Medical Center Harbor-UCLA Medical Center King Drew Medical Center Olive View Medical Center High Desert Hospital CHC/Health Center MI Date of Birth Mo/D/Yr Medical Record Number To Release Protected Health Information To Name of Facility/Health Care Provider/Plan/Other Street Address City for the time period beginning State Zip Code and ending DATE INFORMATION TO BE DISCLOSED PLEA SE CHECK ALL APPROPRIATE BOXES Summary Of Medical History / Treatment Laboratory Diagnostic Tests Discharge Summary Consultation Psychological Testing HIV/AIDS Sexually Transmitted Disease s Mental Illness Or Mental Health Assessment Drug and/or Alcohol Abuse Treatment Other Please Specify History and Physical Medical Progress Notes Radiology Records Radiology Films EKG Report Operative Report THE PURPOSE OF THE DISCLOSURE - PROVIDE A DESCRIPTION OF THE PURPOSE OF INTENDED USE AND DISCLOSURE I understand that health information used or disclosed as a result of my signing this Authorization may not be further used or disclosed by the recipient unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. EXPIRATION DATE This authorization is valid until the following date / Page 2 -AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION Right to Receive a Copy of This Authorization - I understand that if I agree to sign this authorization which I am not required to do I must be provided with a signed copy of the form* Right to Revoke This Authorization - I understand that I have the right to revoke this Authorization at any time by telling DHS in writing. I may use the Revocation of Authorization at the bottom of this form* Mail or deliver the revocation to I also understand that a revocation will not affect the ability of DHS or any health care provider to use or disclose the health information for reasons related to the prior reliance on this Authorization* CONDITIONS I understand that I may refuse to sign this Authorization without affecting my ability to obtain treatment. However DHS may condition the provision of research-related treatment on obtaining an authorization to use or disclose protected health information created for that researchrelated treatment. In other words if this authorization is related to research that includes treatment you will not receive that treatment unless this authorization form is signed* I have had an opportunity to review and understand the content of this authorization form* By signing this authorization I am confirming that it accurately reflects my wishes. Signature Of Patient/Legal Representative If signed by other than the patient state relationship and authority to do so Month Day WITNESS Year REVOCATION OF AUTHORIZATION. EXPIRATION DATE This authorization is valid until the following date / Page 2 -AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION Right to Receive a Copy of This Authorization - I understand that if I agree to sign this authorization which I am not required to do I must be provided with a signed copy of the form* Right to Revoke This Authorization - I understand that I have the right to revoke this Authorization at any time by telling DHS in writing. I may use the Revocation of Authorization at the bottom of this form* Mail or deliver the revocation to I also understand that a revocation will not affect the ability of DHS or any health care provider to use or disclose the health information for reasons related to the prior reliance on this Authorization* CONDITIONS I understand that I may refuse to sign this Authorization without affecting my ability to obtain treatment.

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