• Patient Information
• Emergency Contact Information
• Insurance Information
• Legal Representative of Patient
• Patient History
• Surgical History
• Treatments
• Privacy Practices
• Medication
• Release
• Done

Patient Information

Date / Time Salutation – Select –MrMrsMissMs.Dr.Prof.First Name Middle Name Last Name Patient Date of Birth Marital Status – Select –Single or Never MarriedMarriedWidowedDivorced or SeparatedEmail address Can we send you a portal invitation to PatientAlly.com? (this is a secure place where we send and receive and store your information, results, scripts, and other sensitive information) *** RECCOMENDED*** Yes NoPhone Number May we leave a voicemail ? Yes NoType of Work PreviousNext

Emergency Contact Information

Emergency Contact Employer Email address Emergency Phone Number Emergency Contact Relationship PreviousNext

Insurance Information

Insurance Company Name of Insured Social Security # Relationship of Insured Insurance Policy # Insurance Group # Policy Holder Name Policy Holder DOB Address (if diffrent)Address Line 1 Address Line 2 City State Zip Code Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePreviousNext

Legal Representative of Patient

Skip if not available

Legal Representative Name Relationship – Select –CHILDSPOUSEGUARDIANHEALTH CARE POASELFAddressAddress Line 1 Address Line 2 City State Zip Code Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweEmail Phone/Mobile PreviousNext

Patient History

Please tell us the “REASON FOR TODAY’S VISIT” or any special concerns you would like to discuss today Please list ALL allergies to medications and foods below: Please list ALL medications you are currently taking (including herbal, illicit, over the counter): Preferred Pharmacy Name Pharmacy AddressAddress Line 1 Address Line 2 City State Zip Code Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePharmacy Phone/Mobile Weight Height Race – Select –African American/BlackAsianCaucasianHispanic/LatinoMiddle EasternNative American/AlaskanOtherAny reason you may be pregnant? Yes NoLMP Do you currently smoke? Yes NoIf yes, how many cigarettes/cigars a day? Have you ever smoked? Yes NoIf yes, how many cigarettes/cigars a day? Do you currently chew tobacco? Yes NoIf yes, what type? How Often? Do you consume alcohol? Yes NoIf yes, what type? How Often? Please “CHECK” your PAST MEDICAL HISTORY and explain answers below: Stroke Heart Problems High Blood Pressure Diabetes Arthritis Gout Seizures Depression Anxiety Cancer Bleeding Disorder Alcoholism Tuberculosis Stomach Ulcers Liver Issues Kidney Issues Lung Disease Drug Abuse Other Mental DisordersExplain checked answers: Are you currently seeing another provider for the above issues? Yes NoProviders Name Other Provider Specialty Please “CHECK” FAMILY MEDICAL conditions: Cancer Stroke Melanoma Hepatitis Kidney Disease High Blood Pressure Diabetes Arthritis Anemia HIV Seizures Depression Anxiety Cancer Bleeding Disorder Alcoholism Stomach Ulcers Thyroid Disease Liver Disease Kidney Disease Lung Disease Clotting Problems Drug Abuse Other Mental DisordersPreviousNext

Surgical History

Please circle if you have had any of the following surgical procedures: APPENDECTOMY THYROIDECTOMY HERNIA REPAIR SPINAL SURGERY NECK SURGERY CHOLECYSTECTOMY COLECTOMY CORONARY BYPASS HYSTERECTOMY BREAST SURGERY TUBAL LIGATION CATARACT SURGERY Other Other Surgical History & Years of Surgeries PreviousNext

Consent for Treatment

Consent for Treatment

I, , hereby consent to authorization and treatment voluntarily at
U-First Healthcare, as agreed upon in the best interest of my health.

I consent to the release and disclosure of my medical history, condition, and documentation that is necessary to process insurance claims, assist other medical professionals in continuation of care, or to another healthcare facility if admission is required. I understand that a copy of this signed release is valid as the original. I understand that I or the provider can discontinue this authorization at any time, in writing. I have read and understand this agreement and attest to all the information being provided is true and accurate. I fully accept all terms of this agreement and will receive a copy, if requested.
For Disclosure of Mental Health Treatment Information

I, , WHOSE DATE OF BIRTH IS ,

AUTHORIZE U-First Healthcare TO DISCLOSE TO AND TO OBTAIN ALL MEDICAL INFORMATION
FROM:_______________________________________________________________________________
THIS INFORMATION MAY BE USED OR DISCLOSED IN CONNECTION WITH MENTAL HEALTH TREATMENT,
PAYMENT, OR HEALTHCARE OPERATIONS. I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS
AUTHORIZATION, IN WRITING, AT ANY TIME, BY SENDING WRITTEN NOTIFICATION TO MY PROVIDER’S
OFFICE. I FURTHER UNDERSTAND THAT A REVOCATION OF THE AUTHORIZATION IS NOT EFFECTIVE TO
THE EXTENT THAT ACTION HAS BEEN TAKEN IN RELIANCE ON THE AUTHORIZATION.
UNLESS YOU HAVE SPECIFICALLY REQUESTED IN WRITING THAT THE DISCLOSURE BE MADE IN A
CERTAIN FORMAT, WE RESERVE THE RIGHT TO DISCLOSE INFORMATION, AS PERMITTED, BY THIS
AUTHORIZATION, IN A MANNER WHICH WE DEEM APPROPRIATE AND CONSISTENT WITH APPLICABLE
LAW, INCLUDING BUT NOT LIMITED TO, VERBAL, IN PAPER FORMAT, OR ELECTRONICALLY.
I understand that there is the potential that the protected health information that is disclosed pursuant
to this authorization may be re-disclosed by the recipient and the protected health information will no
longer be protected by the HIPAA privacy regulations, unless state law applies that is more strict than
HIPAA and provides additional privacy protection. I will be given a copy of this authorization for my
records, if requested.

Signature










Sign Here
Today’s Date Signature










Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)
Today’s Date Check here if patient/client refuses to sign authorization Patient/Client refuses to sign AuthorizationSignature of Staff Witness










Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)
Staff Witness Date PreviousNext

NOTICE OF PRIVACY PRACTICES Revised 6-01-2020

NOTICE OF PRIVACY PRACTICES 

Revised 6-01-2020

Right to Request Amendment of Medical Information You Believe Is Erroneous or Incomplete: If you examine your medical information and believe  that some of the information is wrong or incomplete, you may ask us to amend your record. To ask us to amend your medical information, call and  speak to a supervisor. 

Right to Get a List of Certain Disclosures of Your Medical Information: You have the right to request a list of many of the disclosures we make of your  medical information. If you would like to receive such a list, call a Supervisor.  

We will provide the first list to you free, but we may charge you for any additional lists you request during the same year. We will tell you in advance  what this list will cost. 

Right to Request Restrictions on how the Clinic Will Use or Disclose Your Medical Information for Treatment, Payment, or Health Care Operations: You  have the right to request that the Clinic not make disclosures of your medical information to treat you, to seek payment for care, or to operate the Clinic.  

In many cases, the Clinic is not required to agree to your request for restriction, but if we do agree, we will comply with that agreement. If you want to  request a restriction, write to the Supervisor and describe your request in detail.  

However, the Clinic must agree to your request not to disclose to your health plan any medical information about items or services for which you have paid  in full, unless such disclosure is required for treatment or by law.  

If you do not want the Clinic to disclose medical information to your health plan, you must notify us at the time of your registration as well as make  immediate arrangements to pay in full for your treatment. 

Right to Request Confidential Communications: You have the right to ask us to communicate with you in a way that you feel is more  confidential. For example, you can ask us not to call your home, but to communicate only by mail. To do this, write to the Supervisor. Upon  request, you can also ask to speak with your health care providers in private outside the presence of other patients or family. 

Duties of the Clinic: The Clinic is required by law to protect the privacy of your medical information, give you this Notice of Privacy Practices, and follow  the terms of the Notice that is currently in effect. The Clinic is also required to notify you if there is a breach of your unsecured medical information. 

Which Health Care Providers are Covered: This Notice of Privacy Practices applies to the Clinic and its personnel, volunteers, students and trainees.  This Notice also applies to other health care providers when they come to the Clinic to care for patients, such as physicians, physician assistants,  therapists, other health care providers who are not employed by the Clinic. However, these other health care providers may follow different practices at  their own offices or facilities. 

Changes to this notice: From time to time, we may change our practices concerning how we use or disclose patient medical information, or how we will  implement patient rights concerning their information.  

We reserve the right to change this Notice and to make the provisions in our new Notice effective for all medical information we maintain. If we change  these practices, we will publish a revised Notice of Privacy Practices. You can get a copy of our current Notice of Privacy Practices at any time by  contacting the Clinic. 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN  GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

We are committed to protecting the confidentiality of your medical information, and are required by law to do so. This notice describes how we may use  your medical information within the Clinic and how we may disclose it to others outside the Clinic. This notice also describes the rights you have  concerning your own medical information. Please review it carefully and let us know if you have questions. 

How will we use and disclose your medical information? Treatment: We may use your medical information to provide you with medical services and  supplies. We may also disclose your medical information to others who need that information to treat you, such as doctors, physician assistants, nurses,  medical and nursing students, technicians, therapists, emergency service and medical transportation providers, and others involved in your care. 

For example, we will allow your primary care physician to have access to your Clinic medical record. To assure that your other treatment providers have  quick access to your latest health information, we may participate in a community-based electronic health information exchange. We also may use and 

disclose your medical information to contact you to remind you of an upcoming appointment, to inform you about possible treatment options or  alternatives, or to tell you about health-related services available to you, or to perform follow-up calls to monitor your care experience. 

Family Members, Legal Counsel, and Others Involved in Your Care: We may disclose your medical information to a family member, legal counsel,  or friend who is involved in your medical care, or to someone who helps to pay for your care. 

Payment: We may use and disclose your medical information to get paid for the medical services and supplies we provide to you. 

For example, your health plan, Health Insurance Company, or attorney may ask to see parts of your medical record before they will pay us for your  treatment. 

Clinic Operations: We may use and disclose your medical information if it is necessary to improve the quality of care we provide to patients or to run the  Clinic. We may use your medical information to conduct quality improvement activities, to obtain audit, accounting or legal services, or to conduct  business management and planning. For example, we may look at your medical record to evaluate the care provided by clinic personnel, your doctors, or  other health care professionals. 

Required by Law: Federal, state, and local laws sometimes require us to disclose patients’ medical information.  

For instance, we are required to report child abuse or neglect and must provide certain information to law enforcement officials in domestic violence cases.  We also are required to give information to the State Workers’ Compensation Program for work-related injuries. 

Public Health: We also may report certain medical information for public health purposes. For instance, we are required to report births, deaths, and  communicable diseases to the State. We also may need to report patient problems with medications or medical products to the FDA, or may notify  patients of recalls of products they are using. 

Public Safety: We may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law  enforcement officials in response to a search warrant or a grand jury subpoena.  

We also may disclose medical information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report  deaths that may have resulted from criminal conduct at the Clinic. We also may disclose your medical information to law enforcement officials and others  to prevent a serious threat to health or safety. 

Military, Veterans, National Security and Other Government Purposes: If you are a member of the armed forces, we may release your medical  information as required by military command authorities or to the Department of Veterans Affairs. The Clinic may also disclose medical information  to federal officials for intelligence and national security purposes, or for presidential Protective Services. 

Judicial Proceedings: The Clinic may disclose medical information if the Clinic is ordered to do so by a court or if the Clinic receives a subpoena or  a search warrant. You will receive advance notice about this disclosure in most situations so that you will have a chance to object to sharing your  medical information. 

Information with Additional Protection: Certain types of medical information have additional protection under state or federal law.  

For instance, medical information about communicable disease and HIV/AIDS, and evaluation and treatment for a serious mental illness is treated  differently than other types of medical information. For those types of information, the Clinic is required to get your permission before disclosing that  information to others in many circumstances. 

When is Your Authorization Required? Uses and Disclosures for Which Your Authorization is Required: With limited exceptions, the Clinic 

must obtain your written authorization before it may disclose your medical information in the following circumstances: (1) to disclose  psychotherapy notes, (2) to conduct marketing activities, or (3) to sell your medical information to a third party. 

Other Uses and Disclosures Requiring Authorization: If the Clinic wishes to use or disclose your medical information for a purpose that is not discussed  in this Notice, the Clinic will seek your written authorization.  

If you give your authorization to the Clinic, you may take back that authorization any time, unless we have already relied on your authorization to use or  disclose the information. If you ever would like to revoke your authorization, please notify the Supervisor in writing.

NOTICE OF PRIVACY PRACTICES Revised 6-01-2020 Signature










NOTICE OF PRIVACY PRACTICES Revised 6-01-2020 Signature
NOTICE OF PRIVACY PRACTICES Revised 6-01-2020 Signature Date PreviousNext

INFORMED CONSENT FOR MEDICATION

Patient First Name Middle Name Last Name Consent Date Guardian First Name Middle Name Last Name Consent Date Name of Pharmacy Phone/Mobile Pharmacy Address 2Address Line 1 Address Line 2 City State Zip Code Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe

Check Here : I have read and agree to the Terms and Conditions and Privacy Policy

U-First Healthcare offers family medical, psychiatric, medical detoxification, weight management, and  psychotherapy treatments. When meeting with the psychiatric providers the appointment will include  the assessment of your mental health condition and treatment options.  

During the visit, you and your provider will discuss:  

1. The nature of your mental condition.  
2. Your physician’s reasons for prescribing the medication, including the likelihood of your condition  improving or not improving without the medicine.  
3. The importance of medication compliance and the option to discuss with your prescribing physician  any desire to stop taking any medication.  
4. Reasonable alternative treatments that are available for your condition.  
5. There may be a need for initial or periodic medical or laboratory consultations with the use of these  medication(s).  
6. That certain antipsychotic medications may cause additional side effects for some persons, including  tardive dyskinesia. Tardive dyskinesia is defined as persistent involuntary movements of the face,  mouth, torso, hands, or feet. These symptoms are potentially irreversible, and may continue after the  antipsychotic medication has been stopped.  

I was given information about the recommended medication. I understand that the  information does not cover everything, but it includes items of clinical significance to me. I  should discuss all my medical problems and any medication that I take with my healthcare  provider or physician(s). For more information, I may refer to a pharmacist or to a standard  text such as the Physician’s Desk Reference (PDR).  

U-First Healthcare: 1479 Brockett Road Suite 101 Tucker, GA 30084 Office: 1-833-645-4653 Fax: 1-866-892-3005 www.U-First Healthcare.org

MEDICAL / PSYCHIATRY FOLLOW UP VISITS:

Check Here : I have read and agree to the Terms and Conditions and Privacy Policy

Prescribing providers provide prescriptions for medications during appointments. They will rarely approve refill  requests from patients or pharmacies outside of an appointment.  

This practice:  

• – Reduces prescription errors 
• – Improves patient safety and  
• – Encourages appropriate follow-up.  

It also improves compliance with state laws governing controlled substances.  

Patients receive enough medication or refills to last until their next recommended follow-up. It is therefore  important to make and comply with follow-up appointments.  

Please be proactive in your care and track how much medication you have and how many refills remain on your  prescription., and ensure you have an appointment to see the doctor before you run out of medication.  

In instances of emergencies, a fee applies when a patient needs a between-visits refill.  • I understand that I may refuse medication(s) unless the refusal would be unsafe to me/my child or others.  

• Many psychiatric medications can cause sensitivity to sunlight or decrease the body’s ability to handle heat when  being used. Using sunscreen when outdoors and drinking fluids when sweating or in hot settings is good practice  on or off medications.  
• If there are questions about other potential side effects, I know I can contact the prescribing physician. • I understand the potential benefits, side effects, and alternatives and I agree to the medication treatment  recommended.  

Please print, date, and sign your name below indicating that you have read and understand the contents of this  form, you agree to the policies of your relationship with your provider, and you are authorizing your clinician to  begin treatment with you. By signing this you also agree to undergo mental health treatment and understand that  you can end treatment at any time. It should be discussed with your physician, but you always reserve the right to  stop treatment.  

Check this box if you have read and agreed to the Terms and Conditions and Privacy Policy

First Name Last Name MEDICAL _PSYCHIATRY FOLLOW UP VISITS:










Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)
MEDICAL / PSYCHIATRY FOLLOW UP VISIT DATE First Name Last Name Legal Guardian Signature










Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)
MEDICAL / PSYCHIATRY FOLLOW UP VISIT DATE PreviousNext

CONSENT & AUTHORIZATION TO RELEASE INFORMATION

If there are other parties that may assist in your therapy, and you believe it would be helpful for your therapist to  contact them regarding your treatment, please read carefully and complete this document. 

The following is an authorization for the stated parties to consult with one another regarding your treatment process.  Information shared is for the sole purpose of facilitating maximum care to you as the client. Please provide the  necessary information and your signature with today’s date as indicated below.

Check Here : I have read and agree to the Terms and Conditions and Privacy Policy

I,  (client), hereby authorize 

U-First Healthcare and the following party or parties to discuss my mental health treatment information and  records obtained in the course of psychotherapy treatment, including, but not limited to, therapist’s diagnosis: 

Insert trusted parties

Please note that treatment is not conditioned upon your signing this authorization, and you have the right to refuse to sign this form. Please indicate your preference regarding the information to be shared: The parties stated above may discuss my medical and/or mental health information without limitations. I would prefer to limit the information shared between the parties stated above. The limitations I would like to make are as follows: Limitations

Additionally, the above named parties, therapist & person(s) or entity (entities) designated under (1) or (2), agree to  exchange information only between themselves (or their agents). Any disclosure of information extended beyond these  parties is considered a breach of confidentiality. 

Your signature below indicates that you understand that you have a right to receive a copy of this authorization. Your  signature also indicates that you are aware that any cancellation or modification of this authorization must be in writing,  and you have the right to revoke this authorization at any time unless the therapist stated above has taken action in  reliance upon it. Additionally, if you decide to revoke this authorization, such revocation must be in writing and  received by U-First Healthcare at 1479 Brockett Road Suite 101 Tucker, GA 30084 to go into effect. 

First Name Last Name CONSENT RELEASE Legal Guardian Signature










Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)
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