PATIENT REGISTRATION
*****BRING MRI, CT OR X-RAY FILMS OR CD*****
DATE____________________________
PATIENT NAME (LAST, FIRST, M.I.)
____________________________________________________________
STREET ADDRESS ____________________________________________
CITY______________________STATE__________ZIP CODE___________
PRIMARY CARE DOCTOR_______________________________________
REFERRING DOCTOR__________________________________________
SOCIAL SECURITY NUMBER_____________________________________
DATE OF BIRTH_______________________________________________
HOME PHONE___________________WORK________________________
CELL____________________ OTHER_____________________________
EMPLOYMENT STATUS: CIRCLE ONE PLEASE
EMPLOYED RETIRED STUDENT NOT
EMPLOYED
EMPLOYER NAME______________________________________________
EMPLOYER ADDRESS___________________________________________
GENDER: MALE FEMALE
MARITAL STATUS: CIRCLE ONE PLEASE
MARRIED DIVORCED SINGLE WIDOWED
SPOUSE'S NAME_____________________DATE OF BIRTH____________
SPOUSE SOCIAL SECURITY NUMBER______________________________
EMERGENCY CONTACT_________________________________________
PHONE_________________ RELATIONSHIP_________________________
DO YOU HAVE ANY ALLERGIES
_____________________________________________________________
REASON FOR VISIT
_____________________________________________________________
________________________________________
Print Name
ACKNOWLEDGMENT OF RECEIPT
I have reviewed a copy of the Privacy Statement, for Orange Park Neurosurgery P.L. at
2021 Kingsley Avenue, Suite 101, Orange Park, Florida 32073
________________________________ _____________________________
Signature of Patient Date
INSURANCE INFORMATION
Insurance Name ___________________________________________________
Policy Number_______________________Group Number__________________
Address__________________________________________________________
Person Insured__________________Date of birth_________SSN____________
Second Insurance
Insurance Name___________________________________________________
Policy Number_____________________Group Number____________________
Address__________________________________________________________
Person Insured__________________Date of birth_________SSN____________
INSURANCE AUTHORIZATION AND ASSIGNMENT
I authorize payment of medical benefits for any services to me by any providers affiliated with
Orange Park Neurosurgery, to be paid directly to Orange Park Neurosurgery and authorize
release of any medical information necessary to process this claim and request payment for
their services. I understand that I am responsible for any amount not covered by my insurance
of all allowed charges. I understand that I am responsible for my co-pay before seeing the
doctors. I direct my insurance carrier that a photocopy of the authorization shall be considered a
valid assignment of benefits in lieu of the original. This release shall also serve as authorization
to collect from the insurance company or cover any appeals necessary for said collection. It is
mandatory that you tell our office if you know that another party is responsible for paying for
your treatment. Section 1128B of the Social Security Act and 31 USC 3801-3812 provide
penalties for withholding this information.
Patient's Signature_______________________________Date______________________
MEDICAL RECORDS RELEASE
I hereby authorize _____________________________________________________
to release medical records pertaining to my examination, treatment, and prognosis to:
Mark A. Spatola, M.D.
Orange Park Neurosurgery, P.L.
2021 Kingsley Avenue, Suite 101
Orange Park, FL 32073
Phone Number (904) 276-3376
Fax Number (904) 276-5308
A photocopy of this authorization shall be considered a valid release in lieu of the original
Patient Name (print)_____________________________________________________
Patient Signature_________________________________________________________
Date of Birth_____________________________________________________________
Social Security Number_____________________________________________________
________________________________________
Print Name
Orange Park Neurosurgery, P. L.
Dr. Mark Spatola
Name: _____________________________ Date: _________________________
Age: ___________ Referring Physician: _______________
Height: ___________ Primary Physician: ________________
Weight: ___________
Chief Complaint (Reason for visit): ______________________________________
__________________________________________________________________
Medical History: (Check all that apply for self (s), mother (M), father (F)
S M F S M F S M F
( ) ( ) ( ) High Blood Pressure ( ) ( ) ( ) Liver Disease ( ) ( ) ( ) Phlebitis/Blood Clots
( ) ( ) ( ) Heart Disease ( ) ( ) ( ) Kidney Disease ( ) ( ) ( ) Bleeding Disorder
( ) ( ) ( ) Heart Attack ( ) ( ) ( ) Thyroid Disease ( ) ( ) ( ) Asthma
( ) ( ) ( ) Irregular Heart rhythm ( ) ( ) ( ) Diabetes ( ) ( ) ( ) Emphysema/COPD
( ) ( ) ( ) Stroke ( ) ( ) ( ) Osteoporosis ( ) ( ) ( ) Cancer (Type:____)
( ) ( ) ( ) Rheumatoid Arthritis ( ) ( ) ( ) Seizure ( ) ( ) ( ) Trauma
( ) ( ) ( ) Glaucoma ( ) ( ) ( ) Osteo-Arthritis ( ) ( ) ( ) Other:_________
( ) ( ) ( ) Depression/Anxiety ( ) ( ) ( ) Fibromyalgia ( ) ( ) ( ) Other:_________
Surgical History: ( ) Check here if none
Low Back Surgery: (when) _______ (where) ____________ (Surgeon)____________
Neck Surgery: (when) _______(where) _____________ (Surgeon)____________
Heart Surgery: (when) _______(where) _____________ (Surgeon)____________
Joint Replacement: (when) _______(where) _____________ (Surgeon)____________
(which joint) _______________________
( ) Appendix
( ) Gallbladder
( ) Hernia
( ) Hysterectomy (total or partial)
( ) Other: ____________________
( ) Other: ____________________
Allergies: (Check all that apply and list reactions)
( ) Food: _________________ ( ) Penicillin: ___________________
( ) Iodine: _______________ ( ) Sulfa: ___________________
( ) IV Dye: _______________ ( ) Other: ___________________
( ) Latex: ________________ ( ) Other: ___________________
( ) Adhesive tape: _________ ( ) Other: ___________________
_______________________________________
Print Name
Orange Park Neurosurgery, P. L.
Dr. Mark Spatola
Continued Patient Name: ________________________ Date: _____________
Medications: (List name/dose/ how often you take and over the counter (OTC)
medicines)
Medicine Name Dose: How often:
________________ __________ _______________
________________ __________ _______________
________________ __________ _______________
________________ __________ _______________
________________ __________ _______________
________________ __________ _______________
________________ __________ _______________
________________ __________ _______________
________________ __________ _______________
List any over the counter medications, herbals, diet pills or aspirin:
______________________________________________________________
______________________________________________________________
Social History:
Occupation: _________________ ( ) Full-time ( ) Part-time ( ) Disabled ( ) Retired
( ) Married ( ) Divorced ( ) Single ( ) Widowed (Year___________)
( ) Children # ______________
Education: ___________grade ( ) High school ( ) College ( ) Post-graduate
Smoker:( ) Yes ( ) No # of Packs daily _____ How long (Years) ___ ( ) Year Quit ____
Alcohol: ( ) None ( ) Daily ( ) Few per Week ( ) One per week ( ) Occasionally ( ) Rare
Illegal Drug Use: ( ) Never ( ) Other __________
Ever been in Drug/Alcohol Treatment ( ) Yes ( ) No
Exercise: ( ) None ( ) Daily ( ) Few times per week ( ) 1/week ( ) 1/month ( ) Other ____
_____________________________________
Print Name
Orange Park Neurosurgery, P. L.
Dr. Mark Spatola
Continued Patient Name: ________________________ Date: _____________
Review of Systems:
Possibly Pregnant: ( ) Yes ( ) No ( ) Right Handed ( ) Left Handed
( ) None General ( ) Numbness/ Tingling ( ) Local Weakness ( ) Coordination
( ) Taste ( ) Speech ( ) Affect ( ) New incontinence (urine/ Stool)
( ) None Constitutional ( ) Fever ( ) Weight loss ( ) Tiredness ( ) Head Trauma
( ) None Eyes ( ) Blurred Vision ( ) Glaucoma ( ) Double Vision
( ) None Ears/ Nose/ Throat ( ) Deafness ( ) Ringing ( ) Vertigo/Dizziness ( ) Smell ( ) Swallowing
( ) None Heart ( ) Chest pain ( ) Irregular heart rhythm ( ) High blood pressure ( ) Pounding in chest
( ) None Lungs ( ) Shortness of breath ( ) Wheezing ( ) Cough ( ) Emphysema/COPD
( ) Cough up blood
( ) None Abdomen ( ) Diarrhea ( ) Constipation ( ) Black Stool ( ) Heartburn ( ) Stomach Bleeding
( ) None Urinary ( ) Burning ( ) Loss of urine ( ) Blood in urine ( ) Kidney disease
( ) None Menstrual ( ) Regular ( ) Irregular ( ) Severe Pain ( ) Post Menopausal
( ) None Musculoskeletal ( ) Sprains ( ) Rheumatoid Arthritis ( ) Osteo-arthritis ( ) Swelling ( ) Stiffness
( ) None Skin/Breast ( ) Rash ( ) Sores ( ) Lumps ( ) Masses ( ) Cancer: _____
( ) None Neurologic ( ) Balance problems ( ) Memory problems ( ) falls ( ) Neuro disease
( ) None Behavioral ( ) Depression ( ) Anxiety ( ) Sleep Disturbances ( ) Hallucinations
( ) None Endocrine ( ) Thyroid disease ( ) Diabetes ( ) Adrenal disease ( ) Sleep all time ( ) Hyperactive
( ) None Blood/Lymphatic ( ) Easy bruising ( ) Bleeding Problems ( ) Anemia ( ) Sickle Cell
( ) None Immunologic ( ) Itching ( ) Frequent Colds and Infections ( ) HIV ( ) Hepatitis ______ ( ) MRSA
Reviewed:________________________Date: _____________________
Reviewed:________________________Date: _____________________
Reviewed:________________________Date: _____________________