ࡱ> 8:7g RbjbjJJ 4"(b}\(b}\ff*#.FFFFF#######$%'C#QC#FF#i"i"i".FF#i"#i"i"hi"Fs0wi" ##0#i"T(T(i"T(i"i"C#C# #T(f> : WESTSIDE INTERNAL MEDICINE, LLC PATIENT INFORMATION (Please Print) Name: _______________________________________ Date of Birth: __________________ Age: __________ (Last) (First) (Initial) Address: __________________________________________________________________________________ (Street) (City) (State) (Zip) SEX: m M m F Marital Status: m S m M m D m W Social Security #: ___________________________ Home Phone: ______________________ Cell Phone: ________________________________ Employer: ______________________________________________ Work Phone: _____________________ Emergency Contact: _________________________________________________(___)___________________ (Name) (Relationship) (Phone) Race: _________________ m Hispanic m Non-Hispanic Language Preferred: ______________________ Do you rely on transportation such as AmbuStar, Logisticare, etc.? Yes No How did you hear about our practice? _________________________________________________________ Insurance? Name: ______________________ Member/Subscriber No.: _____________________________ Previous Primary Care Provider? Name: ___________________________ Phone: ______________________ Do you give permission to this office to leave a message regarding your appointments, medication and/or lab results?  Home Phone m Yes m No Cell Phone m Yes m No Initial _____________ Email: ___________________________________________________________________________________ I hereby consent to treatment by the ph 12FVW  3 ; F e l { |   ` j       B T v * F L P   , 0 T V x z ~ #$%'7Wտջջͷջճջկկկկջh#hD VhAy-h6hdhbAhfA.h}jhD VUmHnHuh5]h%hV%hdhV%5CJ aJ h6CJ aJ h+ CJ aJ hV%5>*CJ aJ > 2FUVW0 x z N P x z $%~gdV%$a$gdV%$a$gd%$a$gdD VW~Aeh  .26>@lnrtNPRTNPRɶɮhehdhg)5 h^5 hD VhD VU hD V5 hg)5h~6pjhD VUmHnHuhhh5]hdh}hbAh>nh#hD V0@A46tPRT "$&(gdD Vgd>ngdV%ysicians and/or associates of Westside Internal Medicine. I hereby assign my insurance benefits to be paid directly to Westside Internal Medicine. I understand that I am financially responsible for all charges not covered by the assignment. Submitted New Patient paperwork does not constitute a Physician-Patient Relationship. All patients must be seen by one of our Providers to establish a Physician-Patient Relationship. Signature: ________________________________________________ Date: _____________________ (*,.02468:<>@BDFHJLNPRgdV%gdD V21h:pV%/ =!"#@$@% s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List HH ~6p Balloon TextCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]         "WR (R 8@b(  P   "?  P    "?   P    "?   P    "?   P   "? P   "? P   "? P    "? P    "? P    "? P    "? P    "? P    "?   P    "?  B S  ?ab @t 4@t %@t  @t P@td@t A tAgt5dt5dt%YtYt(YtY t 2UV79\`    %,0233K_aa (--:<NO``a  Hqz{{||}KMN..//1122UV    &,0233N_``aaacH  {{||}KMN"!-u6h^%>n+ #V%g)Ay-fA.6&:< JrEM=PWTD V3?m~6p}e#5]dNbAZbl1,@VVVVL@ @UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaA$BCambria Math"qh &y'y'$KdKd!@r43HP ?V%2!xx WESTSIDE INTERNAL MEDICINE, LLC Receptionist2 Front DeskOh+'0   @ L X dpx WESTSIDE INTERNAL MEDICINE, LLCReceptionist2Normal Front Desk17Microsoft Office Word@u@w@A@։"wKd՜.+,0 hp|    WESTSIDE INTERNAL MEDICINE, LLC Title  !"#$%&()*+,-.01234569Root Entry Fx0w;1TableT(WordDocument4"SummaryInformation('DocumentSummaryInformation8/CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q