📋 Medical Forms

Complete your forms online before your visit. Your information is secure and will be sent directly to our office.

🏥

New Patient Packet

Required for new patients. Includes personal information, medical history, insurance details, and consent forms.

Personal Information
Medical History
Insurance Details
Emergency Contact

🩸

Blood Sugar Log

Track your blood sugar readings over time. Record dates, times, readings, and related information.

Date & Time Tracking
Blood Sugar Readings
Meal Information
Medication Notes

❤️

Blood Pressure Log

Monitor your blood pressure readings. Track systolic, diastolic, pulse, and other vital information.

Blood Pressure Readings
Pulse Tracking
Position Notes
Symptom Logging

🏥 New Patient Packet

Personalized Prevention • Your Family & Heart Care
Rhonda Hettinger DNP, NP-C, CLS

1 Patient Information

Name (First M. Last) *

Address *

City *

State *

Zip Code *

Date of Birth *

Social Security Number Optional - Used for insurance verification

Sex *

Marital Status

Spouse's Name

Employer

Home Telephone

Cell Telephone *

Work Telephone

Email Address * Email if you would like us to send you email reminders of appointments

2 Emergency Contact Information

Emergency Contact (Name, Phone Number, Relation and Address) *

3 Primary Insurance

Insurance Company

Policy/ID Number

Group Number

Carrier of Insurance

If carrier of insurance is different than patient, please fill out below:

Name

Date of Birth

Social Security Number

Relationship to Patient

4 Secondary Insurance (if applicable)

Insurance Company

Policy/ID Number

Group Number

Carrier of Insurance

If carrier of insurance is different than patient, please fill out below:

Name

Date of Birth

Social Security Number

Relationship to Patient

5 Assignment of Benefits & Consent

I hereby assign, transfer, and set over to Your Family and Heart Care Center with Personalized Prevention, all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance.

I hereby consent to routine diagnostic procedures and medical treatment provided through Your Family and Heart Care Center with Personalized Prevention and I understand that no guarantee of results has been made.

Patients who fail to present for a scheduled appointment, without contacting the office 24 hours prior to their appointment, will be considered a "no show". A fee of $35.00 will be charged directly to the patient, not the insurance. Patients who are assessed a "no show" fee MUST pay this fee before their next appointment is scheduled.

Patient Signature *

Date *

6 HIPAA Authorization to Release Information

In accordance with the HIPAA Guidelines, I hereby authorize Your Family and Heart Care Center with Personalized Prevention to discuss my medical information with the following:

Name 1

Relationship

Phone

Name 2

Relationship

Phone

Name 3

Relationship

Phone

I hereby authorize Your Family and Heart Care Center with Personalized Prevention to leave a detailed message on my answering machine.

Yes No

7 HIPAA Privacy Practices Acknowledgment

Your Family and Heart Care Center with Personalized Prevention is concerned about the privacy of our patient's health care information. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care service will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.

Name of Patient (Please Print) *

Patient Signature or Authorized Representative *

Date *

9 Medication Record

PCP Name

PCP Phone

Medication Allergies & Reactions

List all Medications you are currently taking (Prescription and OTC)

Medication Name

Strength

Directions

Reason for Taking

Prescriber

11 Authorization to Release Information and Payment

I authorize Your Family and Heart Care Center Care with Personalized Prevention LLC to bill my insurance carrier on my behalf for services rendered. I understand that I am financially responsible for any amount not covered by my insurance carrier. I authorize Your Family and Heart Care Center Care with Personalized Prevention LLC to release to my insurance carrier any information concerning my health care, advice, treatment, or supplies provided which may be necessary to secure payment of these claims.

Patient Printed Name *

Patient Signature *

Date *

🩸 Blood Sugar Log

Track your blood sugar readings over time. Record each reading with the time and any relevant notes.

1 Patient Information

Full Name *

Email Address *

Phone Number

Date of Birth

Insurance Provider

2 Monitoring Period

Start Date *

End Date *

Testing Frequency

3 Blood Sugar Readings

Enter your blood sugar readings for each day. Fill in the readings for each time of day.

Date	Before Breakfast	After Breakfast	Before Lunch	After Lunch	Before Supper	After Supper	Bedtime

Medications Taken

Notes

❤️ Blood Pressure Log

Monitor your blood pressure readings. For accurate results, measure at the same time each day.

1 Patient Information

Full Name *

Email Address *

Phone Number

Date of Birth

Insurance Provider

2 Monitoring Period

Start Date *

End Date *

Testing Frequency

3 Blood Pressure Readings

Enter your blood pressure readings for each day. Fill in the readings for Morning and Evening.

Date	Symptoms	MORNING			EVENING
		Top	Bottom	Pulse	Top	Bottom	Pulse

📋 Medical Forms

New Patient Packet

Blood Sugar Log

Blood Pressure Log

🏥 New Patient Packet

1 Patient Information

2 Emergency Contact Information

3 Primary Insurance

4 Secondary Insurance (if applicable)

5 Assignment of Benefits & Consent

6 HIPAA Authorization to Release Information

7 HIPAA Privacy Practices Acknowledgment

8 Patient History Form

Past Medical History (Please answer Yes or No)

Family Medical History

Social History

9 Medication Record

List all Medications you are currently taking (Prescription and OTC)

10 Review of Symptoms

General

HEENT

Neck

Lung

Heart

Stomach

Endocrine

Blood/Lymphatic

GU

Musculoskeletal

Skin

Allergy

Neurologic

Psychiatric

Women

Men

11 Authorization to Release Information and Payment

🩸 Blood Sugar Log

1 Patient Information

2 Monitoring Period

3 Blood Sugar Readings

❤️ Blood Pressure Log

1 Patient Information

2 Monitoring Period

3 Blood Pressure Readings

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