All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Name Date Of Birth Choose one Female Male Choose one European African American Asian Hispanic Other Primary Language English Spanish Vietnamese Other Marital Status Married Single Partnered Divorced Separated Widowed Address Phone * Phone Primary Care Physcian (Name, Phone, Address) Referring Physcian (Name. Phone, Address) Emergency Contact (Name, relation to patient, phone, address) I authorize Rheumatology Center Of Houston to discuss my medical condition and/or treatment, if needed, with: (Name, relationship to me, phone number) Responsible Party Address (If different than patient’s) Primary Insurance Carrier (Subscriber name and DOB, individual ID, group ID) Secondary Insurance Carrier (Subscriber name and DOB, individual ID, group ID I Have No Insurance I agree to pay today for the services rendered by Rheumatology Center of Houston, PLLC. Pharmacy Information (Name, address, phone, fax) Patient Communication Consent: We may need to contact when you are not in the office. This is to acknowledge that you authorize us to: Leave a detailed message on voicemail. Yes No Leave a detailed message with individual answering the phone. Yes No Email you using an encryption software. Yes No Text you. You understand that standard charges will apply through your mobile carrier. Yes No Other requests for confidential communications: By typing my name below I authorize Rheumatology Center of Houston, PLLC to contact me by the above communication methods. I have had a chance to ask any questions that I had and to receive answers. I have been proactive about asking questions related to this consent agreement. My questions have been answered and I understand and concur with the information provided in the answers. Date Acknowledgement of receipt of privacy practices: Notice to patients: We are required to provide you with a copy of our Privacy Practices which state how we may use and/or disclose your health information. Please print your name below to acknowledge receipt of the Privacy Practices. You may refuse to sign the acknowledgement. Date Acknowledgement of receipt of office policies. By typing my name below I acknowledge that I have read the office policies. I have had a chance to ask any questions that I had and to receive answers. I have been proactive about asking questions related to these policies. My questions have been answered and I understand and concur with the information provided in the answer. Date SubmiT