Anna Rosinska M.D. 3316 Andrews Hwy Midland, TX 79703 (432) 688-1900 www.AskDrAnna.com Patient Information and Medical History NAME_________________________________________________________________________________________
(STREET) (CITY) (STATE, ZIP) PHONE # WITH AREA CODE____________________________________________________________________
(WORK) (CELL) EMPLOYER ______________________________________ OCCUPATION ______________________________ DATE OF BIRTH________________AGE______ SEX: F M SS # __________ -- ______--_________ DRIVER’S LICENCE # _______________________________STATE _________________ EXP ______________ EMERGENCY CONTACT ______________________________________RELATIONSHIP__________________ ADDRESS ______________________________________________________________________________________
(STREET) PHONE # WITH AREA CODE____________________________________________________________________
WOULD YOU LIKE TO RECEIVE OUR MONTHLY EMAIL? YES NO EMAIL ____________________________________________________ HOW DID YOU FIND OUT ABOUT US? _____________________________________________
************************************************************************ Allergies of any kind (food, meds)___________________________________________________________________ Current/recent medications:_______________________________________________________________________
Height: ______ft ________in Weight: ________________ Desired Weight: _________________ Please mark if you have any of the medical conditions: Diabetes High Blood Pressure Heart Problems Mitral Valve Prolapse Palpitations Bleeding Problems (low platelets count, hemophilia, blood dyscrasia) Taking anti-inflammatory meds (Aspirin, Motrin, Aleve, Naprosyn, Mobic) or Blood Thinners? History of recurrent Cold Sores / Fever Blisters / Herpes Pregnant or planning to get pregnant in the nearest future? Yes No Any other medical conditions? If yes, please explain _________________________________________________ I ATTEST THE ABOVE INFORMATION TO BE TRUE, KNOWING MY PROVIDER RELIES ON THIS INFORMATION TO PROVIDE SAFE AND EFFECTIVE TREATMENT.
Due to the popularity of our services, we have found it necessary to implement the following policy regarding the scheduling of appointments. Once scheduled all appointments require a minimum of 24 hour notice for cancellation. Failure to follow this policy will result in the following: Missing 1 appointment without notice: $ 25.00 Charge. Missing 2 appointments without notice: $ 50.00 Charge. Missing 3 appointments without notice: $ 75.00 Charge. No future appointments will be honored until the above fees are paid. For Complimentary and Gift Certificate Appointments: Missing ANY complimentary appointment without a 24-hour notice will result in Complete Forfeiture of the appointment. Gift Certificates are subject to the same charges as regular appointments. I have read and fully understand this policy and agree to follow the terms within.
Signature ___________________________Date ________
A copy of this agreement will be provided to you upon request.
HIPAA POLICIES AND PROCEDURES We are permitted to disclosure protected health information (PHI) to those involved in the treatment of your medical conditions (ER physicians, hospitals, ect). We also may disclose PHI without your written authorization. We are not allowed to release PHI to anyone without written consent. If the patient is a minor (under 18 years of age) we can only release PHI to parent or legal guardian, If the patient is an adult but incapacitated or unable to sign for his/her medical records we are allowed to disclose PHI to the person that has power of attorney after submitting a copy of the legal documentation. We are not permitted to disclose PHI received from another physician to a patient. Information has to be obtained directly from this physician. PRINT NAME: _______________________________ SIGNATURE: ________________________________ DATE: ______________________
BIOMARKERS IN EEL TO EVALUATE EFFECTS OF DIQUAT IN A CHRISTCHURCH RIVERL A TremblayLandcare Research, CENTOX, PO Box 69, Lincoln 8152, New Zealand. E-mail: [email protected] received, 30/5/03; resubmitted, 4/12/03; accepted, 8/12/03. ABSTRACTChristchurch City Council uses herbicides for the control of exotic plant species in and around the waterways throughout Christchu
Committee: Security Council Briefing Paper: Pharmaceutical Companies and their Role in the Developing World What’s the issue? The modern pharmaceutical industry is a lucrative one, with the largest ten pharmaceutical companies in the world each featuring in the top 400 companies in the world (for example, the USA based pharmaceutical company Pfizer reported sales of $45,083