REGISTRATION FORM

Today’s date:

2615 Fannin Houston, Texas 77002

PATIENT INFORMATION

Patient’s last name: First Name: Middle Name:

Age: Birth date: Marital Status (circle one) Single Married Divorced Sex:

/ / Separated Widow M F

Street address: Home phone no.: Cell phone no.:( ) ( )

City: State: ZIP Code:

Social Security no.: Email address:

Chose clinic because/Referred to clinic by (please check one box):

Family Friend Close to home/work Yellow Pages Other____________________________

Hospital___________________________________ Dr.__________________________________

IN CASE OF EMERGENCY

Name of local friend or relative: Relationship to patient: Home phone: Cell phone:

The above information is true to the best of my knowledge. I understand that if any such information is found to be false, I may be denied access to care at San Jose Clinic.

Patient Signature / or Guardian signature if a minor Date

FOR OFFICE USE ONLY

MRN #: _______________________________ Information verified by:______________________

New patient _____Address/Phone update______

GENERAL CONSENT FORMSAN JOSÉ CLINIC

I hereby voluntarily consent to medical and/or dental examinations, treatments and or procedures including laboratory tests and x-rays, which are deemed necessary in the opinion of my physician/dentist and health care providers selected by my physician/dentist.

ACKNOWLEDGEMENTSI acknowledge the following:

A. San José Clinic utilizes volunteers and volunteer health care providers who may provide care to me that is not administered for or in expectation of compensation; and

2615 Fannin Houston, Texas 77002

B. In exchange for receiving treatment and health care services from such volunteers and volunteer health care providers, limitations exist on my ability and right to recover damages against such volunteers and volunteer health care providers.

C. I understand that no guarantees or warranties have been made to me concerning the results of the examinations, treatments or procedures. My signature acknowledges that I have been given the opportunity to satisfy myself by asking questions about this consent form.

D. I understand that the doctors and/or staff of the San José Clinic are available when the clinic is open and are not available for after-hours consultation or advice. I understand that if I have a question or need medical attention after hours, I must seek the care of an Emergency Room or other physician/dentist.

E. This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 U.S.C. §§ 1346(b), 2401(b), 2671-80) provides the exclusive remedy for damage from personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by any free clinic volunteer health care practitioner who the Department of Health and Human Services has deemed to be an employee of the Public Health Service. This FTCA medical malpractice coverage applies to deemed free clinic volunteer health care practitioners who have provided a required or authorized service under Title XIX of the Social Security Act at a free clinic site or through offsite programs or events carried out by the free clinic (See 42 U.S.C. § 233(a), (o)).

F. I have received and understand San José Clinic’s Notice of Privacy Practices.

MY SIGNATURE BELOW ACKNOWLEDGES THAT I HAVE BEEN GIVEN THE RIGHT TO ASK QUESTIONS AND RECEIVE INFORMATION AND HAVE HAD MY QUESTIONS ANSWERED AND HAVE RECEIVED ALL INFORMATION REQUESTED ABOUT THIS ACKNOWLEDGEMENT AND I KNOWINGLY AND VOLUNTARILY SIGN THIS ACKNOWLEDGEMENT. I FURTHER ACKNOWLEDGE THAT THE VOLUNTEERS AND VOLUNTEER HEALTH CARE PROVIDERS RENDERING HEALTH CARE SERVICES TO ME ARE DOING SO IN RELIANCE ON MY EXECUTION OF THIS ACKNOWLEDGEMENT. A PHOTOCOPY OR A FAXED COPY OF THIS ACKNOWLEDGEMENT SHALL BE DEEMED AS VALID AS THE ORGINAL.

Additionally, I acknowledge that I have received notice of privacy practices.

____________________________________________________________________ __________________________Signature of Person Authorized to Consent (Patient, Parent or Legal Guardian) Date

____________________________________________________________________ __________________________Printed Name of Person Authorized to Consent ( Parent, Legal Guardian) Relationship to Patient

___________________________________________________________________ __________________________Patient’s Printed Name Date of Birth

___________________________________________________________________ _________________________Patient’s Address Zip Code Patient Telephone Number

2615 Fannin Houston, Texas 77002

Designation to Release Confidential Medical Information

______________________________ ________________________Patient Name Date of Birth

Some patients prefer that other individuals, especially family members, be allowed access to their medical information. In accordance with Federal government privacy rules, a written release is required to allow another person access to your medical records. This release grants permission to individual(s) listed below to: make or confirm appointments, have access to x-ray and laboratory findings, pick up medication, be made aware of your diagnosis, prognosis, and treatment plans, and serve as your emergency contact.

I do NOT give permission for anyone else to be contacted other than myself I give permission to contact the following people:

Name Telephone Relation to Patient

Please mark your selection

1. pick up medications make appointments receive medical information

2. pick up medications make appointments receive medical information

3. pick up medications make appointments receive medical information

**IF NOTHING IS SELECTED ABOVE THIS FORM WILL BE INVALID**

Answering Machine MessagesThere may be times when our office is not able to reach you by telephone. With your permission, we would like to be able to leave messages on your home answering machine or voice mail. Home voice mail? Yes No Cell phone voice mail? Yes No

_______________________________________ __________________Patient Signature Date

2615 Fannin Houston, Texas 77002