WELCOME NEW ARGYLL PATIENTS
Welcome to Argyll Medical Group where our motto is "Upgrade to Personal Service Family Medicine". Your new patient packet has several forms that will assist us in providing you the best possible healthcare service.
Medi-Cal Acknowledgement: We are not contracted with Medi-Cal. As a result, we can not establish a relationship with a patient who is insured with this insurance.
Patient Information/ Responsibility Party Information: We ask patients to provide us with their specific personal information to register them as an Argyll patient and for administration purposes.
Consent for Release of Medical Records use: Argyll will take care of obtaining your medical records with this form.
Office Policy on Medication Refills: This informs patients on Argyll’s refill policy on Medications and Mail Away Pharmacies.
Missed Appointment Fee and Cancellation Fee: This informs patients of our missed appointment cancellation appointment
Patient Financial Policy and Statement: Argyll asks patients to work with us to remain the health care provider of choice in the area by fairly paying for services rendered. We find establishing a clear financial agreement with patients from the beginning helps avoid misunderstandings.
Assignment of Insurance Benefits and Collection Policy: We are happy to work with patients to bill their insurance. This form authorizes Argyll to bill the insurance on behalf of the patient. It also provides important information to clarify the patient’s responsibility for any charges not covered by their insurance.
Patient Acknowledgement of Receipt of a Notice and Access of Privacy Practices and Consent / Limited Authorization and Release form & Communication Preferences / Patient Portal Account: This informs patients of Argyll's Privacy Practices, Private Health information release, communications preferences and Patient Portal Access. Other resources new patients should be aware of:
Finance Department: We make an effort to be there for you if you have temporary difficulty meeting your financial responsibility for the health services you and your family need. The Finance Department can also answer questions about your bill. New patients should inquire about our Convenience Payment Options.
Group Manager: Argyll is known for our policy of openness with our patients and our "customer service" philosophy for healthcare. Patients are encouraged to bring up concerns or praise regarding the service they receive. Patients may meet with the manager in person, via e-mail, or complete a quality survey.
Personal Service: Argyll is sincere in our commitment to delivering "Personal Service Family Medicine". Our staff is particularly approachable and reachable during business hours. Make sure to take your Argyll physician’s card for the direct number to your office and discuss with the staff the best way to get your concerns addressed in a timely manner. Patients might also consider taking our Business Information and Directory card to their pharmacy etc. to ensure administration between our offices is handled with the convenience and efficiency which Argyll patients have become accustomed.
For any Referrals or Pre-authorization requests, patients may be subject to additional fees based on time spent to complete.
Each practice independently owned. Management services provided by Argyll Medical Group LLC.
There are many questions below that we ask you to answer. They may help me better understand how to treat the concern that brought you here today. They might also remind you of other issues you’d like addressed. Depending on their nature, some of these issues may be covered today and some others may require a separate office visit so we can give them the time and attention they deserve.
Adult History Medical Form
First Name (required)
Last Name (required)
What concern do you wish me to address today? (required)
Please list all medicines you are currently taking, including doses and times. (required)
Please list any allergies or bad reactions you have to medications. (required)
Please approximate your last appoint dates for the following:
Fasting blood sugar check
(50 and up) Colon cancer screening
(65 and up) Pneumonia Shot
Past Medical History
Please check the conditions that apply to you.
Any major illnesses or injury in the last 5 years Head/Brain injuries, disorders or illnesses Seizures, epilepsy Eye disorders or impaired vision (except Glasses or contacts) Ear disorders, loss of hearing or balance Heart disease or heart attack Heart surgery (valve replacement/bypass, Angioplasty, pacemaker) High blood pressure Muscular disease Lung disease, emphysema, asthma, chronic bronchitis Kidney disease, dialysis Liver disease Digestive problems Diabetes or elevated blood sugar Nervous or psychiatric disorders Sleep disorders Stroke or paralysis Missing or impaired hand, arm, foot, leg, finger, toe Spinal injury or osteoporosis Chronic low back pain Regular, frequent alcohol use Narcotic or habit forming drug use
Other conditions not listed above (list below):
When was your last period?
When was your last pap smear?
When was your last mammogram?
If applicable, When did you last have a Bone Mineral Density scan?
Please check all that apply to you.
** For Everyone
Have you ever had any surgeries? Yes No
Surgical History Details
Have you been hospitalized in the past? Yes No Family History
Are there specific health problems that are common in your family? Yes No Social History
If applicable, how much you smoke now, or have you smoked regularly in the past?
If applicable, how much do you drink alcohol?
If applicable, How much do you smoke?
If applicable, how much alcohol do you regularly intake?
Review of symptoms that have may have troubled you over the past month. Please check all that apply to you.
Unexplained weight change, fevers, chills or night sweats Vision changes, eye pain, redness, irritation, light bothering eyes, double vision, blurred vision Hearing loss, nasal congestion, snoring Low back or joint pain Chest pain, feeling unusual heartbeats, fainting, needing to sleep on more pillows to breath easily Shortness of breath at rest or increasing with exercise, chronic cough Nausea, vomiting, diarrhea, changes in stool Urinary urgency, increased frequency or pain Frequent nighttime urination, problem with sexual function Frequent heartburn Problem with memory Rashes or itching, non-healing sores, easy bruising or bleeding tendencies Excessive thirst, feeling unusually hot, cold or tired Lymph node swelling or pain Frequent headaches, loss of consciousness, numbness, weakness Problems with depression or anxiety Problems with allergy Other conditions not listed above (describe below)
Other conditions not listed:
Please select a provider
(required) Your Signature