Patient Information Sheet

Name___________________________________ Birth date_______________ Sex: ____M____F

Lives with: ____Mother ____Father ____Both ____Other
Ethnicity______________________ Race__________________
Mothers Name:_____________________________________ Birth Date:__________________
SS#:_______-______-________

Address:_____________________________________

City, State, Zip:_________________________________________________________________

Home#: (_____)_______________ Work#(_____)_____________ Cell#(______)____________
Email:______________________________ Employer:_________________________________
Fathers Name:_____________________________________ Birth Date:__________________
SS#:_______-______-________

Address:_____________________________________

City, State, Zip: _________________________________________________________________

Home#: (_____)_______________ Work#(_____)_____________ Cell#(______)____________
Email: ______________________________ Employer:_________________________________
Insurance Information:
Insurance Company: _____________________________________________________________
Insurance ID#: ___________________________________ Account/Group#:________________
Effective Date: __________________
Subscribers Name: ______________________________ Relationship to Patient_____________
Address: ______________________________________________________________________
Languages Spoken: ______________________________________________________________
Emergency Contact OUTSIDE of household: ________________________Phone:____________
Allergies: __________________________________________Medications__________________

Hospital Admissions/Surgeries: ____________________________________________________

Family History of: ____Diabetes

____Heart Problems

____High Blood Pressure

____Cholesterol

____Asthma

____Leukemia

____Cystic Fibrosis

____AIDS/HIV

____Tuberculosis

____Kidney Problems
____Cancer of_________________

Coral Springs Holistic Pediatrics, LLC

9750 NW 33rd Street #216
Coral Springs, FL 33065-4081
Tel: 954 752-8446
Fax: 954-752-8464
E-mail: DrPHealth@aol.com

To be used for records to be sent to Richard Presutti, MD/Linda Colon, MD

From: __________________________________________________________________
Doctor or Hospital

__________________________________________________________________
Address

__________________________________________________________________
City, State, Zip

Tel#

Thereby authorize and request release of photocopies of the following medical records in your
possession or control.
PROBLEM LIST
LAST TWO WELL CHECK VISITS
LAST TWO SICK VISITS
LAST GROWTH CHART
FULL IMMUNIZATION RECORD
CONSULTS
**FOR CHILDREN 6 MONTHS AND YOUNGER, PLEASE PROVIDE ALL
MEDICAL RECORDS
______________________________________________________________________________
For the purposes hereof, Medical Records shall include all confidential HIV- related information
(as defined in ARS Section 36-661), confidential communicable- disease related information (as defined in
ARS Section 36-8810), confidential alcohol or drug abuse-related information (as defined in 42 CFR
Section 2.1 ET SEQ) and confidential mental health diagnosis/treatment information.

Name: __________________________________________ DOB: _________________

__________________________________________ DOB: _________________
__________________________________________ DOB: _________________
Address: _______________________________________________________________________
_______________________________________________________________________
Signature: ______________________________________________________________________
(If relative, state relationship)

Witness: ________________________________________
Date: _____________________________
This authorization is valid for 1 year from signing date.

Coral Springs Holistic Pediatrics, LLC

Richard A Presutti, MD Linda Colon, MD
9750 NW 33rd Street #216
Coral Springs, FL 33065-4081
Tel: 954 752-8446
Fax: 954-752-8464
E-mail: DrPHealth@aol.com

1) We are required by law to maintain the privacy of, and provide individuals with, this
notice of our legal duties and privacy practices with respect to protected health information. If
you have any objections to this form, please ask to speak with our HIPPA Compliance Officer
in person or by phone at our Main Telephone Number.
Signature below is only acknowledgement that you have received this Notice of our Privacy
Practices.
Print name: _____________________________________________
Signature: ____________________________________________ Date:_________________
2) It is this office policy that charges/co-pays and outstanding balances be paid at the time of
each visit. I accept financial responsibility for the charges incurred on my childs behalf.
In the event that insurance is filed for the services rendered, I hereby authorize this office
to release information to my Insurance Company and assign benefits to Coral Springs
Holistic Pediatrics, LLC, Richard Presutti, MD and/or Linda Colon, MD. I agree that
should this account be referred to an agency or attorney for collection, that I will be
responsible for all collection costs, attorneys fees, all court costs an interest of 1.5% per
month
Signature: ____________________________________________ Date:_________________
3) I hereby grant permission to a download of historical medication history on my child.
Signature: ____________________________________________ Date:_________________