Adult New Patient Packet

New Patient Information

This questionnaire will take about 10-20 minutes to complete.
Name (First Middle Last)*
Name you like to be called
Birth Date*

MonthDayYear
Date
Social Security Number
Preferred Language
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address (only complete if different from Mailing Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Preferred Pronouns
Legal Gender
Ethnicity (required by Vaccine program, Medicare, or insurance)

American IndianHispanic/LatinoAsianAfrican AmericanNon-Hispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDecline to specify
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email address
example@example.com
initial here GPC may leave detailed voice messages at my home phone
initial here GPC may leave detailed voice messages at my cell phone
initial here GPC may text message me at my cell phone
initial here GPC may use Spruce to message and text with me
Choose one initial Allow email: GPC may send my personal health information via email. I understand that email may be unencrypted and that this carries risk of a third party gaining access. I also understand that emails may be part of my permanent medical record. I also give permission for GPC to communicate via email with my specialists and other outside providers as indicated through my release of information form.
-OR-
initialDo not allow email: I do not wish to have email initiated from GPC. I understand that if I email GPC they may respond to my request via email.
initial GPC may speak to the person indicated below about my medical condition. This may include information related to mental/behavioral health, substance abuse, sexually transmitted disease, HIV status and reproductive medicine unless specified below field.
Name/Relationship: Name/Relationship
Phone #: Area Code Phone Number
Emergency Contact

NameRelationship
Emergency Contact Address (if different from yours)
Home/Cell Phone Number of Emergency contact
Please enter a valid phone number.
Work Phone Number of Emergency contact
Please enter a valid phone number.
Preferred Pharmacy
Cross streets
Guardianship - If applicable please list who has legal guardianship and their phone number:
With my signature below, I acknowledge and understand that this information will be kept in my medical record according to and the instructions above will be honored until revoked by me in writing. It is my responsibility to notify GPC should I change one or more of the telephone numbers listed above.

Clear
Today's date

MonthDayYear
Date

Greenlake Primary Care Financial Policy

Greenlake Primary Care does not participate with any private insurance which means we will not bill any private insurance on your behalf.

As a patient, you can expect that we will:
- Provide accurate and timely billing.
- Provide your bill to you in paper or electronically (e-statements), depending on your preference.
As a patient or guarantor, this is what we ask of you:
- Payments for incidental services outside of DPC membership are due at the time of service.
- Monthly fees are paid at the first of the month, if credit card is declined we ask that you promptly assist us in updating your credit card.
- If your account falls more than 60 days behind you may be asked to leave our practice.
For your convenience we accept both Visa and Master Card, and ACH payments (through HINT only).

Checks returned for insufficient funds will result in an immediate charge of $35.00 against your account.

We require at least 24-hour notice if you are unable to keep your appointment. Missing an appointment without notice and/or late cancel is considered a no show. Repeated no shows may result in a charge of up to $50.00 ($175 for psychiatric appointments A third no show within 12 months may result in dismissal from the practice.

Questions about your account can be answered by

Tess Moore, MD (206)524-5656

Credit Card Authorization:

I authorize Greenlake Primary Care to charge my credit on file for both my monthly fee as well as incidental charges. These include charges collected for labs, medications, late fees as above, and other incidentals that will be explained to me prior to any payments being rendered. Credit card numbers and ACH will be entered directly by me or staff into the secure payment system HINT or directly into our online credit card terminal through Transaction Express. No card numbers or bank information is stored in my chart or in the office and the card number, cannot be accessed once entered.
- I can ask and receive a statement of my account which the practice will provide within 5-7 business days.
- Start date of authorization is pursuant to start date of my signed membership agreement.
- The authorization is in effect until rescinded in writing.
I understand that Greenlake Primary Care does not bill insurance, and therefore will not release my information to any health insurance company unless directed by me with written notification.

When patients turn 18 years old, they become the guarantors of their account. They will be asked to review their own financial agreements the first time they have a visit after turning 18.

I have read and understand this policy. A copy will be kept in my chart and a copy may be furnished to me at my request.
Signature

Clear
Today's date

MonthDayYear
Date
Printed name of signer

Medical History
Briefly state your main concerns with your health
Please list your medical problems and the month/year it began
condition month/year began
condition    month/year began
condition    month/year began
condition    month/year began
condition   month/year began
condition   month/year began
condition   month/year began
condition   month/year began
condition month/year began
Please list any surgeries, injuries, and hospitalizations with approximate date
surgery/hospitalization date
surgery/hospitalization      date
surgery/hospitalization      date
surgery/hospitalization      date
surgery/hospitalization      date
surgery/hospitalization      date
Medication/Supplement - Dose - Frequency or Number
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
Allergies to Medications/Food
medication/food and reaction
medication/food and reaction
medication/food and reaction
medication/food and reaction
medication/food and reaction
medication/food and reaction
Family History for genetic (first-degree) relatives
Father living (Y/N) - age or age at death health problems list medical problems
Mother   living (Y/N) - age or age at death   health problems   list medical problems
Brother   living (Y/N) - age or age at death health problems   list medical problems
Brother   living (Y/N) - age or age at death   health problems   list medical problems
Sister   living (Y/N) - age or age at death   health problems   list medical problems
Sister   living (Y/N) - age or age at death   health problems   list medical problems
Preventive Care
enter dates for any you have had
mammogram date
pap smear date
bone density (DEXA)   date
abdom aneurysm test   date
EKG   date
heart stress test  date
heart catheterization   date
eye exam   date
Preventive Care
continued
colonoscopy date
stool colon cancer test date
endoscopy   date
chest X-Ray   date
chest CT   date
Tb test  date
Hepatitis C test   date
HIV test  date
Vaccines - enter dates for any you have received
Flu date
Pneumococcus date
Tetanus   date
Hepatitis B   date
Shingles   date
HPV   date
COVID #1/2   date
COVID booster   date
If applicable
number of pregnancies/births #/#
Problems with periods
days of flow
age of start of periods   #
age at menopause (if applicable)   age
Hot flashes   Abnormal pap

New Patient Information