REGISTRATION FORM

(Please Print)

Mark Farber MD, PhD
4849 Van Nuys Blvd, Suite 202
Sherman Oaks, CA 91403
Office 818-784-5300, Fax: 302-219-6613

Today's date:
PCP:

PATIENT INFORMATION
Patient's last name: First name: Middle name:
Is this your legal name? If not, what is your legal name? : (Former name): Birth Date: Age: Sex:
Street address: Cell phone no: Home phone no:
City:
State:
ZIP Code:
Occupation:
Employer:
Employer phone no:
Referred by:
Pharmacy:
Name/Phone number:
E-mail:

INSURANCE INFORMATION

(Please give your insurance card to the receptionist)

Person responsible for bill:
Birth date:
Address (if different):
Home phone no:
Is this person a patient here? Yes No
Occupation:
Employer:
Employer address:
Employer phone no:
Is this patient covered by insurance? Yes No
Please indicate primary insurance:
Insurance Insurance Insurance Insurance Insurance Insurance Insurance Welfare (Please provide coupon) Other
Subscriber's name:
Subscriber's S.S. no.:
Birth date:
Group no.:
Policy no.:
Co-payment: $
Patient's relationship to subscriber: Self Spouse Child Other
Name to secondary insurance (if applicable):
Subscriber's Name:
Group no.:
Policy no.:
Patient's relationship to subscriber: Self Spouse Child Other

IN CASE OF EMERGENCY
Name of local friend or relative:
Relationship to patient:
Home phone no.:
Work phone no.:
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize or the insurance company to release any information required to process my claims.
Patient/Guardian Signature
Date

4849 Van Nuys Blvd, Suite 202
Sherman Oaks, CA 91403
Office 818-784-5300, Fax: 302-219-6613

Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or text address from the Practice.

I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number or email to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information to the following Cell Phone number:

Cell Phone Number:

I authorize to receive email/text messages for appointment reminders and general health reminders/feedback/information in the Patient Portal to the following Email Address:

The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).
Signature Name (please print) Date

Acknowledgement of Receipt of Notice of Privacy Practices

Leo Labunsky, M.D.

Mark Farber MD, PhD

Allen Ameri, M.D.

Mark Braunstein, M.D.

Pavel Goykhman, M.D.

Mikhail Vizel, M.D.

4849 Van Nuys Blvd, Suite 202
Sherman Oaks, CA 91403

I hereby acknowledge that I received a copy of this medical practice’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area and that I will be offered a copy of my amended Notice of Privacy at each appointment.

Signed: Date:
Print Name: Telephone:

If not signed by the patient, indicate relationship:

Name of Patient:

Consent to Use Telemedicine

Patient's name : My Doctor's Name :

CONSENT TO USE TELEMEDICINE

I am physically located in California. At the beginning of each telemedicine session, I will help my doctor complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication. By signing this consent, I understand and agree:

  1. My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help.
  2. I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor’s staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.
  3. My doctor believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.
  4. a If my doctor believes at any time that another form of service (for example, a traditional in-person consultation) would be appropriate, my doctor may discontinue telemedicine services and schedule an in-person consultation with my doctor or refer me to a healthcare provider in my area who can provide such services.
  5. a I have the right to withdraw consent to the use of telemedicine services at any time and receive in-person healthcare services with my doctor.
  6. I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology, which may require an in-person consultation.
  7. a I agree to have the necessary computer, equipment, and internet access for my telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy that is free from distractions and intrusions during my telemedicine communications.
  8. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.
  9. a I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to "autoremember" usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.
  10. [I agree to be videotaped and recorded during the telemedicine services. I understand the resulting images and audio will become part of my medical record.] OR [No part of the encounter will be recorded without my written consent.]
  11. I have the right to access my medical information and obtain copies of my medical records in accordance with California law.
  12. I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.

I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with my doctor and all of my questions were answered to my satisfaction.

     
Date   Patient’s signature

New Patient

Medical History form

Mark Farber MD, PhD
4849 Van Nuys Blvd, Suite 202
Sherman Oaks, CA 91403
Office 818-784-5300, Fax: 302-219-6613

Full name : Date :
Birth Date : Age :

allergies No allergies

Allergy Allergic Reaction

MEDICATIONS

MEDICATIONS

(Please list All)

 Dose

(MG, Pill, Etc.)

 Times Per Day
If you need more room to list medications, please write them on a blank sheet of paper with the required information.

HEALTH MAINTENANCE SCREENING TEST HISTORY

MEDICATIONS Date Facility/Provider Abnormal Result? (Y/N)
CHOLESTEROL
COLONOSCOPY/SIGMOID
MAMMOGRAM
PAP SMEAR
BONE DENSITY

New Patient

Medical History form

Mark Farber MD, PhD
4849 Van Nuys Blvd, Suite 202
Sherman Oaks, CA 91403
Office 818-784-5300, Fax: 302-219-6613

OTHER HEALTH ISSUES continued...

SEXUAL ACTIVITY Sexually involved currently? Y N (If no sexual history, please continue to Exercise)
Sexual partner(s) Is / are / have been: Male Female
Birth control method: None Condom Pill/Ring/Patch/Inj/IUD Vasectomy
EXERCISE Do you exercise regularly? Y N (If you answered no, please move to Sleep)
What kind of exercise? Duration : How long (min):         How often:
SLEEP How many hours, on average, do you sleep at night (or during the day, if working night shift)?
DIET How would you rate your diet? Good Fair Poor Would you like advice on your diet? Y N
SAFETY Do you use a bike helmet? Y N Do you use seat belts consistently? Y N
Working smoke detector in home? Y N If you have guns at home, are they locked up? Y N
Is violence at home a concern for you? Y N Have you completed an Advance Directive for Health Care (ADHC), Living Will, or Physical Orders for Life-Sustaining Therapy (POLST)? Y N

OTHER PROVIDERS/SPECIALISTS

SPECIALIST NAME LAST VISIT
Cardiology
Gastroenterologist (GI)
OB/GYN
Neurology
Pulmonary
Other:
Other:

ADDITIONAL INFORMATION

Have you traveled outside of the country in the last 30 days? If yes, where?
Have you served in the military? If yes, how long and what branch?
Were you deployed? If yes, where?
Patient name: DOB

New Patient

Medical History form

Mark Farber MD, PhD
4849 Van Nuys Blvd, Suite 202
Sherman Oaks, CA 91403
Office 818-784-5300, Fax: 302-219-6613

PERSONAL MEDICAL HISTORY

DISEASE/CONDITION CURRENT PAST COMMENTS
Alcoholism/Drug Abuse
Asthma
Cancer
Depression/Anxiety/Bipolar/Suicidal
Diabetes
Emphysema (COPD)
Heart Disease
High Blood Pressure (Hypertension)
High Cholesterol
Hypothyroidism/Thyroid Disease
Renal (Kidney) Disease
Migraine Headaches
Stroke
Other:
Other:

SURGERIES

TYPE (Specify Left/Right) Date LOCATION/FACILITY

WOMEN S HEALTH HISTORY

Date of Last Menstrual Cycle: Age of First Menstruation: Age of Menopause:
Total Number of Pregnancies: Number of Live Births:
Pregnancy Complications:
Patient name: DOB

RECORDS RELEASE AUTHORITY



(Patient’s name or guardian)

You release to:

Leo Labunsky, M.D.
Allen Ameri, M.D.
Mark Braunstein, M.D.
Mark Farber MD, PhD


Address: 4849 Van Nuys Blvd, Suite 202 Sherman Oaks, CA 91403
Telephone: 818-784-5300
Fax: 302-219-6613

A report of my diagnosis, treatment, prognosis, and recommendations, as well as other data pertinent to your treatment of me
from: to
 
Date of Request:
Patient’s Signature:
Print Name:
D.O.B.:
Patient’s Address :
City, State, Zip Code:
Witness:
Today's Date: