If you are interested in receiving medical
care through our services, it is possible to arrange for an
appointment with the front desk (click here for connection to
the front desk e-mail-
frontdesk1@gordonclinic.com state your preferences as
to time of the day and day of the week).
The Gordon Clinic is not an emergency facility, therefore, if
you feel you have a serious medical emergency, we recommend that
you go to the nearest hospital. This form may be filled prior to
your visit to the Gordon Clinic or completed on arrival.
In order to download our form in
Word Format,
please click in this link.
Si usted está interesado/a en recibir atención médica en nuestro
centro médico comunitario, usted puede enviar un e-mail a
nuestra recepcionista haciendo click en este enlace,
frontdesk1@gordonclinic.com. Explique en su mensaje
como ponernos en contacto con usted además de por e-mail,
teléfono, etc, sus preferencias con respecto a la hora y el día
de la semana que prefiere. Igualmente, no vacile en describir
brevemente sus síntomas.
Note sin embargo, que la clínica no tiene un servicio de
emergencias y depende de los servicios de Fire Rescue: para
traslado inmediato a un hospital. Por lo tanto, si usted tiene
una emergencia seria, le recomendamos que se dirija directamente
a un hospital acreditado. La forma de registración es muy
sencilla y debe de ser completada antes de recibir atención
médica. Si usted la trae consigo, por favor entréguela a la
recepcionista cuando llegue a la clínica.
Para hacer el :download: de la forma haga click en
Word Format
por favor.
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THE GORDON CLINIC |
Fee |
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Cuota
$__ |
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YEARLY
REGISTRATION |
PATIENT
INFORMATION |
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Planilla de
Registro Anual |
Información del
Paciente
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Date/Día___ |
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NAME/ Nombre |
___________________________________________ |
SEX/ Sex___ |
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ADDRES/ Dirección |
_________________________________________ |
PHONE/Teléfon___ |
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CITY/ Ciudad |
___________________________________________ |
ZIP CODE/ Zona
Postal___ |
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DATE
OF BIRTH/ Fecha de Nacimiento |
___________________________ |
AGE/ Edad__ |
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STATUS/ Estado
Civil MARRIED/ Casado
o SINGLE/Soltero
o WIDOW/ Viudoo DIVORCED/Divorciadoo |
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SOCIAL SECURITY
No. |
__________________________________________ |
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OCCUPATION/
Ocupación |
________________________________________ |
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EMPLOYED BY/
Empleado por |
_____________________________________ |
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ADDRES/
Dirección |
______________________________________ |
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SPOUSE/ Nombre
del esposo |
___________________________________ |
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OCCUPATION/
Ocupación |
___________________________________ |
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EMPLOYED BY/
Empleado por |
___________________________________ |
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ADDRES/
Dirección |
____________________________________________ |
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PERSON RESPONSIBLE
FOR PAYMENT |
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Persona Responsable por el
pago_______________________________________ |
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ADDRESS/
Dirección________________________________________________ |
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INSURANCE/Seguro Yes/Sí
o
NO/No
o |
MEDICAL/Médico
o
HOSPITAL/Hospital
o |
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NAME
OF THE COMPANY/Nombre de la Compañía______________________ |
DEDUCTIBLE/Deducible$_______________ |
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CERTIFICATE No./Certificado No.________ |
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POLICY No./ Póliza No.
_____________________________________________ |
MEDICAID___________________________ |
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Policy #
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ALERGIES/Alergias
___________________________________________________________ |
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PRESCRIPTION YOU
ARE TAKING /Medicinas que está tomando Actualmente
– NEW PATIENTS ONLY / Pacientes nuevos solamente-
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1
_________________________ |
3
_____________________________ |
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2
__________________________ |
4
_____________________________ |
PHYSICIAN RELEASE &
ASSIGNMENT-1 hereby authorize payment directly
to................................................of
benefits due to me
from my insurance company otherwise payable to me.
I further authorize the
release of any medical information required by my insurance
carrier's.
A copy of this
authorization may be used in lieu of the original.
I authorize any holder
of medical or other Information about me to release to the Social
Security Administration and Healt Care Financing Administration or
its intermediaries or carriers any Information needed for this or a
related Medicare claim. I request payment of medical insurance
benefits either to myself or to the party who accepts assignment.
I understand that I and
financially responsible for charges not covered by this
authorization.
PATIENT'S SIGNATURE
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OFFICIAL USE/USO OFICIAL |
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ID |
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INS |
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FEE |
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CREDIT CARD |
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REFERRED BY/
Referido por________________________ |
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BELOW YOU WILL FIND A LIST OF SYMPTOMS AND AILMENTS. PLEASE
CHECK THOSE CONDITIONS YOU REMEMBER AS HAVING HAD ANYTIME IN
THE PAST. IF THIS IS NOT A NEW REGISTRATION, JUST REPORT NEW
SYMPTOMS SINCE LAST REGISTRATION WAS FILLED.
A continuación usted va a encontrar una lista de síntomas y
enfermedades. Haga el favor de marcar claramente aquellas
que usted ha tenido o padecido en el pasado. Si esta no es
una planilla de registro nueva, solo reporte lo síntomas
nuevos desde su ultima planilla. |
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HEADACHES |
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Dolor de cabeza |
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RASH |
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Erupción |
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HAIR CHANGE |
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Cambio en el pelo |
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NASAL BLEEDING |
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Hemorragia nasal |
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SINUSITIS |
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Sinusitis |
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SHORTNESS OF BREATH |
o
Falta de aire |
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ASTHMA |
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Asma |
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CHEST PAIN |
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Dolor en el pecho |
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PALPITATIONS |
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Palpitaciones |
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WEIGHT LOSS |
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Pérdida de peso |
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ABDOMINAL PAIN |
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Dolor Abdominal |
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o
BLOOD IN STOOLS |
o
Sangre en las heces fecales |
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o
BLACK STOOLS |
o
Heces fecales negras |
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o
DIARRHEA |
o
Diarreas |
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o
GALL STONES |
o
Cálculos biliares |
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o
BURNING ON URINATION |
o
Ardor al orinar |
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o
BLOOD IN THE URINE |
o
Sangre en la orina |
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KIDNEY STONES |
o
Cólico Nefrítico |
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oCONSTIPATION |
o
Estreñimiento |
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INCONTINENCE |
o
Incontinencia |
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NUMBNESS |
o
Adormecimiento |
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SYNCOPE |
o
Síncope |
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DECREASED VISION |
o
Disminución de la vision |
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RINGING IN THE EAR |
o
Zumbido de oídos |
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PARALYSIS |
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Parálisis |
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TREMORS |
o
Temblores |
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THYROID PROBLEMS |
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Problemas de Tiroides |
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DIABETES |
o
Diabetes |
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HIGH BLOOD PRESSURE |
o
Presión alta |
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HIGH CHOLESTEROL |
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Colesterol alto |
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VENERAL DESEASES |
o
Enfermedades venéreas |
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ULCERS |
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Úlceras |
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ARTHRITIS |
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Artritis |
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SEIZURES |
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Convulsiones |
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HEPATITIS |
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Hepatitis |
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TUBERCULOSIS |
o
Tuberculosis |
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ANEMIA |
o
Anemia |
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BLOOD TRANSFUSIONS |
o
Transfusiones de sangre |
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In order to download the
remainding forms required for registration in Word format, please
click on each of the forms below.
Para hacer el "download" de
los siguientes formularios en el formato de "WORD,"
haga click en cada uno de los documentos cuyos títulos aparacen aquí
debajo por favor.
Anti – Kickback Statement
PATIENT CONSENT
FORM
REPORT OF NON-ROUTINE DISCLOSURES
PATIENT AUTHORIZATION FORM
NOTICE OF PRIVACY
PRACTICES ACKNOWLEDGEMENT
LIVING WILL
MEDICAL MALPRACTICE
INSURANCE
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