New Patient Packet

Patient Name *

First Name Middle Name Last Name

Sex

Male Female

Address

Street Address

Street Address Line 2

City State

Zip Code

Phone Number (Home)

Area Code Phone Number

Ok to leave message?

Yes No

Phone Number (Cell)

Area Code Phone Number

Ok to leave message?

Yes No

Phone Number (Work)

Area Code Phone Number

Ok to leave message?

Yes No

Birthdate

Month Day Year

Employer

Payment Method

Bill insurance Cash

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Relationship

Phone Number (Home)

Area Code Phone Number

Phone Number (Cell)

Area Code Phone Number

Phone Number (Work)

Area Code Phone Number

1.

How long?

2.

How long?

3.

How long?

1.

How long?

2.

How long?

3.

How long?

Parents

Siblings

Other members

Patients who have Substance Use Problems:

	Yes/No	Quantity	Frequency	How Long
Tobacco
Alcohol
Substance
Substance
Intravenous Use

Inpatient:

Outpatient:

Suboxone Treatment Program

Counseling Or Chemical Dependency Program

Surgeries:

Hospitalizations / Emergency Room visits not listed above:

Significant Illness not listed above:

Have you ever had suicidal thoughts or thoughts of harming yourself?

Have you ever had an overdose?

Medication allergies and sensitives (please include type of reaction)

Have you ever had a serious allergic or an prophylactic reaction?

Yes No

Please list your current medications

	Drug / medicine	Reason	Dose	Frequency	How long?
1.
2.
3.
4.
5.

Please list additional medications here:

Please list any vitamins, herbs, or supplements you are taking now

General

Recent weight gain or loss Fevers Night sweats Other

Head and Neck

Headaches Dizziness Dental problems Sinus infections Other

Heart

Chest pain Palpitations Blood pressure Irregular heartbeat Swollen legs Murmur Other

Lungs

Cough Shortness of breath Asthma Frequent bronchitis or pneumonia Other

Gastrointestinal

Genital or Urinary

Frequent urination Prostate infections Hernias Frequent bladder Kidney infections Blood in urine Sexually transmitted disease Other

Muscular and Skeletal

Neurologic System

Pain Loss of sensation Loss of function of arms Loss of function of legs Tremors Other

Psychological

Major changes in your life

Death Divorce Job Move Other

Skin

Rashes Itching Infection Eczema Psoriasis Bruising Other

Hormone

Thyroid Female Male Adrenal Other

Other

Bleeding Bruising Anemia

Please elaborate on anything asked above:

Dr. Markus is not contracted with insurance. Appointments and Payment is due at time of service through our Cloud Clinic website: https://creeksidemedicine.vsee.me/u/telehealth

OFFICE HOURS - Dr. Markus sees patients Monday, Wednesday and Thursday from 8AM until noon. He may be available at other times which can be arranged on an individual basis. He is working at the hospital in the afternoons. Our phones are open from 9:00 AM to 1:00 PM, Monday through Thursday, and closed on Friday. Please email us at reception@creeksidemedicine.com after 1:00 PM if you have concerns that require a response by end of business day. If you have questions that can wait until the next business day please leave a voicemail at our main number. We will answer voice mail and email on Friday mornings as well. At other times and on weekends Dr. Markus is available for urgent calls through our voice mail system. If there is ever a medical emergency, please call 911.

PRESCRIPTION REFILLS - Please call your pharmacy when you need a prescription refilled. If needed, they will call us for approval. This process can take up to (2) business days so try to anticipate your medication needs in advance of weekends and holidays.

MEDICAL RECORDS - All your records are confidential. NO information will be released (even to family) without your signed consent. If you authorize us to release information to others this process can take up to (2) weeks. Please review HIPAA compliance law RCW 70.02 for a full disclosure of how we will manage your health information.

APPOINTMENTS - Please arrange your appointment through the following website. https://creeksidemedicine.vsee.me/u/telehealth. This is the only way to schedule appointments so please do so! We do charge a fee between $45 and $90 for missed appointments or appointments cancelled without 24 hours notice.

ABOUT INSURANCE - As a courtesy to our patients we will be happy to bill your insurance. Please verify with your insurance regarding payments for out of network physicians.

FINANCIAL INFORMATION - We accept Debit, Visa and Master Card, paid through our Creekside Cloud Clinic system.

*

By checking this box and signing below, I understand and accept the terms of the above-described financial policy/disclosure. I understand I am individually responsible for payments of all charges. I have had an opportunity to view the NOTICE OF PRIVACY PRACTICES.

Patient Signature: *

First Name Last Name

Date

Month Day Year

Signature of person responsible for bill, if not patient:

Signature:

First Name Last Name

Relationship to patient:

Creekside Center

11416 Slater Ave NE Suite 203B

Kirkland, WA 98033

New Patient Packet

Patient Registration

Emergency Contact

Current problems in order of priority:

Please list chronic problems you have had for years, not listed above:

Family history of medical/psychiatric/mental health or substance use:

Substance Use Treatment Programs:

Past Medical History:

General Body Review

Procedures and Financial Policy

Patient Agreement