onlineformmale

Patient Name *

First

Last

Responsibility Parties Names for Minors (Parent or Legal Guardian) *

First

Last

Date of Birth (mm/dd/year) *

Age *

Email *

Patient Address *

Line 1

Line 2

City

State

Zip Code

Country

How may we contact you? *

Phone Email Text

Marital Status *

Consent for Use and Release of information *

I give permission to Murdock Health – including its treating and referring providers and other staff members – to release any information about me, my health, the health services provided to me, or payment for my health services, that may be necessary: (1) for my treatment (to health care providers or facilities that need the information for my continued care); (2) for any purposes related to payment by me or a third party for services (to determine eligibility, to process an insurance claim, for utilization and quality review, or for billing or collection purposes, as necessary to obtain payment). For more detailed information about the way my information may be used or released, I can read the Murdock Health’s Notice of Privacy Practices.

Authorization *

I AM THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SUBMIT THIS FORM.

Name of Person Submitting Form *

Date Submitted (mm/dd/year) *

Phone Number *

Sex *

Occupation *

Pharmacy Name *

Pharmacy Phone Number *

Emergency Contact Name *

Emergency Contact Phone Number *

How did you hear about our office? *

Acknowledgement of Privacy Practices *

The Notice of Privacy Practices is a complete description of my privacy rights as a patient of Murdock Health, PLLC. By checking this box, I am stating that I have received Murdock Health’s Notice of Privacy Practices.

Consent for Treatment/Care *

I consent to treatment and care by Murdock Health, PLLC physicians and health care providers. I understand that my treatment and care may include routine care, such as immunizations, and a variety of other medical services depending on my condition, such as laboratory testing. I authorize Murdock Health health care providers to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I can receive a list of services and care from my health care provider. I am aware that the practice of medicine (including surgery) is not an exact science, and no one has made any guarantees about the results of my treatments, examinations, or procedures.

Notice of Privacy Policies
File Size:	31 kb
File Type:	odt

Male Patient Registration and Health History Form
(Please complete and submit the Form below. All asterisks must be completed to submit the form.)

Male Patient Registration and Health History (ALL ASTERISKS MUST BE COMPLETED TO SUBMIT FORM)

Services

Murdock health, PLLC

Office hours

Male Patient Registration and Health History Form ​(Please complete and submit the Form below. All asterisks must be completed to submit the form.)

Male Patient Registration and Health History (ALL ASTERISKS MUST BE COMPLETED TO SUBMIT FORM)

Services

Murdock health, PLLC

Office hours

Male Patient Registration and Health History Form
(Please complete and submit the Form below. All asterisks must be completed to submit the form.)