[Hi , Welcome {NAME} Click Here
Dear (r) Rachelarnold121, Registered Company Name: Trading Name: Registration Number: Registration Date: Business Type: (Pty) Ltd CC (Close Corporation) T/A (Sole Proprietor) Partnership Other Specify: VAT Registration Number: Physical Address: Code: Postal Address: Code: Telephone No: ( ) Facsimile No: ( ) Mobile No: Email Address: Approximate Monthly Purchase Amount: Finance Contact: Contact Number: ( ) Email Address: Banking Details: Name of Bank: Branch Code: Account Number: Trade References: Company Telephone Contact Credit Limit 1. ( ) R 2. ( ) R 3. ( ) R Cardinal Station Newburg Center for Primary Care
215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215 Central Avenue, Suite 205
Louisville, KY 40208 Louisville, KY 40218 Louisville, Ky 40208
I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components
UofL Department of Family & Geriatric Medicine
Dear New Patient,
Welcome to your University of Louisville Physicians Family practice! We
are offering patient-centered medical care and are enthusiastic about our
relationships with our patients. In order to better serve your needs, we are
enclosing several forms and ask that you completely fill each form out.
The first sheet will help us learn more about you; please completely fill out this
form about your family history. The next sheet is titled, âAuthorization for the
use and/or Disclosure of Protected Health Informationâ, and you will need to
completely fill that out for our doctors to treat you to the best of their ability; it
gives us permission to review your medical records from your previous primary
medical facilities.
Following, please completely fill out the Registration, Social Services & Consent
Form. Next, you will find our Privacy Notice, followed by an acknowledgement that
you have received and understand our Privacy Policies. Finally, the last form is the
Office Acknowledgements and Policies form. Please read carefully and sign
your name at the bottom of the letter.
Please make sure to bring all of these forms with you to your first office visit.
Do not mail them back to the office. Also, please remember to always
bring your picture ID, current insurance cards and your co-payment. If your
health insurance requires you to select a primary care doctor please do so prior to
your office visit. Please bring in any and all medication you take, in their
original bottles, to your appointment.
If the patient is under 18 years of age he or she must be accompanied by an
adult and will need to bring a copy of their current immunization certificate.
Please arrive 15 minutes ahead of your scheduled appointment time so that if
you have questions about these forms or we need more information, we can
a ddress it all prior to your appointment.
We look forward to seeing you!
University of Louisville Physicians
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INSCRIPTIONS 2018-2019 Publié le 2 septembre 2018 par joel Bonjour, Le processus dâ??inscription se modernise, car nous avons mis en place cette année un site WEB vous permettant de réaliser cette opération depuis chez vous à partir du lien situé en bas de ce message.Cependant, si vous rencontrez des difficultés, des permanences sont mises en places au gymnase Henri Barbusse, tous les soirs de 17h00 à 19h00 pour vous aider en cas de besoin, pour faire votre inscription en ligne.](