Patient Registration Form The answers to your questions or concerns are one click away. Please complete the online form and receive a response within 24 hours. First Name*Last Name*Street Address*APT Number*City*State*Zip*Home Phone*Work Phone*Other Number*Date of Birth* Email Address* *MaleFemale*SingleMarriedAge*Social Security Number*Occupation*Employee Name*Employee Address*Emergency Contact Name*1st Phone*Relationship*2nd Phone*Family Physician*Telephone Number*Date Of Last Examination* Fax*Pharmacy Name*Fax*Insurance Information ENT Patient(only if applicable) Please give card to receptionistPrimary Insurance Carrier*Policy*$ Co-Pay*Refferals Needed*YesNoCarrier Provider Phone*Group*Insurance Address*How did you hear of Dr. Dagan* Physian Zoc Doc Newspaper TV/Radio Friend Yellow pages Internet Other Patient Medical HistoryName*Date* Specific Reason For Visit/Consultation*Date of Birth* Height*Weight*Allergies: (List Any reactions you have had to medications and describe the symptoms)*Medications : ( List All prescription, over-the-counter & herbal medications you have taken recently with dosages)*Past Medical History: (List Any medical conditions for which you have been treated)*Past Surgical History: (List All previous surgery; include complications or abnormal reactions to anesthetics)*Social History*Exercise*Cigarette Smoking:*YesNoQuitPack (s) Per Day) For*Years*Alcohol*NoneSocialHeavyCoffee*YesNoCup Per Day*Drug Use*NoneSocialYesSubstanceAre you currently pregnant?*NoYesIf Yes, How Many Months?Family History: (check any of the following that effect first degree relatives and relationship* Anesthetic Problems Breast Cancer Mental Illness High Blood Pressure Diabetes Hereditary Diseases Heart Disease Bleeding Disorders Other Check any illness or conditions you have or had in the past* Diabetes Glaucoma Heart trouble Chicken pox Cancer Asthma Jaundice Gonorrhea Antibiotic use Mumps Pneumonia Allergies Kidney disease Bleeding tendencies Rheumatic fever Nervous Disorder Measles Syphilis Multiple Sclerosis Mononucleosis High fevers Tuberculosis Hepatitis Polio Gonorrhea Vein Trouble HIV Other Are you currently receiving care from a* Chiropractor Acupuncturist Medical Dentist Physical Therapist Massage Therapist Nutritionist Other Comments*Name*Date* General* Fatigue Sleep Problems Swollen Glands Hot or Cold Intolerance Weight loss Fever or Chills Allergies Nervousness Depressed Irritable Head (headache: note which area)* Entire Head Back Of Head Forehead Temples Migraine Head Feels Heavy Loss Of Memory Light-Headed Fainting Sensitivity To Light Loss Of Smell Loss Of Taste Loss Of Balance Dizziness Loss Of Hearing Pain In Ears Buzzing In Ears Nervous System* Dizziness Blurred Vision Fainting Paralysis Tremors Numbness/Tingling Convulsions Imbalance Neck* Pain In Neck Neck Pain W/movement Pinched Nerve In Neck Neck Feels Out Of Place Stiff Neck Muscle Spasms In Neck Popping Sounds In Neck Arthritis In Neck ENT* Earache Ear Discharge Ringing In Ears Hearing Loss Nose Bleeds Hoarseness Problems Swallowing Sore Throat Jaw Tight Or Sore Dental Problems Glasses/Contacts Skin* Easy Bruising Dry Skin Itching Boils Rashes Excessive Sweat Hair Changes Heart/Lung* Chest Pain High Bood Pressure Low Blood Pressure Hard To Breathe Coughing Blood Coughing Phlegm Irregular Heartbeat Varicose Veins Ankle Swelling Gastrointestinal* Change In Appetite Thirst Nausea Vomiting Diarrhea Constipation Hemorrhoids Gall Badder Belching Heartburn Abdominal Pain Bloody/Black Stool Liver Trouble Gas/Indigestion Cancellation Policy Please be advised of our cancellation policy. The fee for all cancellations is $100 UNLESS this office is notified at least 24 hours prior to the appointment. In the event of a true emergency, exceptions can be made Please understand that another patient may be able to use your cancelled slot Thank you.Date* Signature*All Private Insurance I authorize the release of all medical information necessary to process this claim and that is pertinent to my medical care. I assign all medical and/ or surgical benefits, including major medical benefits to which I am entitled, to the provider of services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as a valid as the original The Medicare Patient I request the payment of authorized Medicare benefits be made to me or on my behalf to the provider for any services furnished to me by that provider. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents, any information needed to determine benefits payable for released services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. Agree to be financially responsible for all charges including but not limited to any medical related fees and any fees incured in collection of any outstanding balance including attorney fees. I have read this information and understand it. I understand that in the case my insurance provider issues payment for any service rendered by Dr. Tal Dagan or any of his employees, that payment shall be sent promptly to Dr. Dagan. In the case payment issued for services by Dr. Dagan or his employees is not forwarded within one month, I will be responsible for the payment amount and any legal cost necessary to procure payment in addition to accrued interest at 25%.Date* Patient Name*To all our new and established patients, I appreciate and respect that you have chosen to receive medical service at my office. Many Insurance plans now place a higher burden on their members, requiring higher copayments, coinsurances and deductibles depending on the type of service. Furthermore, when we verify your coverage, your insurance company will not guarantee the information they provide us is accurate and up to date, nor would they guarantee payment for a particular service. As a result, we have implemented a new policy for the office which now requires all patients to provide us with a valid credit card number prior to services being rendered. You will be asked for a credit card number at the time you check in and the information will be held securely until your insurance has paid their portion and notified us of the amount of your share of the claim. At that time, any remaining balance owed by you will be charged to your credit card and a copy of that charge will be mailed to you. You will also receive an explanation of benefits from your insurance company detailing the fee that is your responsibility, so the charge should not come as a surprise to you. Copayments, previous balances and any remaining deductible due at time of your visit will, of course, still be sue at the time of your visit. We will continue to bill your insurance carrier, but should your insurance company decline to accept responsibility for any part of your visit, your credit card will be charged for the difference. This will not compromise your ability to dispute a charge, or question your insurance company’s determination of payment. If you have any questions about this payment method, do not hesitate to ask us. I thank you for your understanding of this policy. Sincerely, Dr. Tal DaganPatient Consent To Credit Card ChargesDate* Cardholder Signature*I authorize Tal Dagan MD, F.A.C.S to charge my credit card for the balance of charges not paid by my insurance carrier (additional copayment, coinsurance or deductible). I assign my insurance benefits to the provider listed above. I understand that this form is valid for one year unless I cancel the authorization through written notice to Dr. Tal Dagan.Card Type*VisaMaster CardAmerican ExpressOtherFirst Name*Last Name*Name As On Credit Card*Credit Card Number*Expiration(MM/YY)*CVV*Billing Address*City*State*Zip Code*Mail Receipt:*CC Billing AddressChart Home AddressPERSONAL ACKNOWLEDGEMENT OF RECEIPT OF NOTICE This is to acknowledge that: I have received and reviewed Tal Dagan MD PC Notice of Privacy Practice: I understand that I can contact the Practice Privacy Office at (212) 585-3242Date* Signature 0f Patient/Personal Representative* This iframe contains the logic required to handle Ajax powered Gravity Forms.