221 E Hacienda Ave.

, Ste B
Campbell, CA95008
t 408.376.3350
f 408.374.4130




PATIENT REGISTRATION (Please print & complete all information)

Patient Name: M F Birthdate:
Last First
SS#: - - Marital status: Single/Married/Widow/Divorced
Address: City: Zip:
Home Phone: Cell Phone: Work Phone:
Email:
Can we leave a detailed message at the above numbers? Yes No
Referred by:
Spouse/Significant Other: SS#: - -
Birthdate:
If patient is a minor:
Mothers Name: DOB: Work #:
Fathers Name: DOB: Work #:
EMERGENCY CONTACT (NOT LIVING WITH YOU)

Name: Home#: Work#:
Relationship:
INSURANCE INFORMATION

Employer:
Primary insurance:
Policy Subscriber Name: Self Spouse Other
Subscribers DOB:
Secondary insurance:
Policy Subscribers Name: Self Spouse Other
Subscribers DOB:

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the physician to release any information acquired in the course of
my treatment necessary to process insurance claims. It is your responsibility, as holder of the insurance policy, to check your
insurance coverage. I understand that I am financially responsible for all charges for services rendered.
A finance charge of 1.5% will be added monthly for accounts outstanding after 60 days. I have read and understand.

Date: Signed:

Medication Allergies:



Please fill out this form in its entirety. Please complete every line item, as it is necessitated
by government regulation (Health Care Finance Administration HCFA)

PATIENT INFORMATION
Patient Name: Date:
DOB: Height: Weight
Referring Physician: Primary Care Physician:
I. What are you being seen for today? ______________________________________________
Medical History
Diabetes O Yes O No
Stroke O Yes O No
Arthritis O Yes O No
Osteoporosis O Yes O No
Colon Cancer O Yes O No
Breast Cancer O Yes O No
Other Medical problems:


Ovarian Cancer O Yes O No
Prostate Cancer O Yes O No
High Blood Pressure O Yes O No
High Cholesterol O Yes O No
Heart Attack/Heart Disease O Yes O No
Skin Cancer O Yes O No



Allergies
Are you allergic to any medications?
O Yes O No
If yes, please list:
Are you allergic to food or environmental substances?
O Yes O No
If yes, please list:
Social History

Do you smoke cigarettes? O Yes O No
Have you ever smoked cigarettes in the past? O Yes O No
If yes, when did you quit? ____________________________________________________________
How long have you smoked? O <1 year O 1-10 years O 10+ years
How many packs per day? O <1 pack O 1-2 packs O 3+ packs
When are you planning to quit? O Now O Next 6 Months O Sometime O Never
Do you drink alcohol regularly? O Yes O No
How many drinks per day? O < 1 drink O 1 drink O 2-3 drinks O 4+ drinks
Have you ever had a blood transfusion? O Yes O No
Do you participate in sports/recreational activities? O Yes O No
If yes, please list _____________________________________________________________.
Where were you born? _________________________________________________________________________________
Have you lived in any other countries? O Yes O No
If Yes, Where? _______________________________________________________________________________________
Are you married or in a monogamous relationship? O Yes O No
Do you observe Safe Sex practices 100% of the time? O Yes O No
Any toxin exposures at work or home? O Yes O No
Other Physicians that you see: Physicians Name: Specialty:
__________________________ ____________________________
__________________________ ____________________________



Family History

Mother DOB: ____________________________ O Living O Deceased
O Diabetes O Stroke O Osteoporosis O High Blood Pressure
O Arthritis O Colon Cancer O Breast Cancer O Ovarian Cancer
O Prostate Cancer O Skin Cancer O High Cholesterol O Heart Attack/Disease
O Other ____________________________________________________________________________

Father DOB: ____________________________ O Living O Deceased
O Diabetes O Stroke O Osteoporosis O High Blood Pressure
O Arthritis O Colon Cancer O Breast Cancer O Ovarian Cancer
O Prostate Cancer O Skin Cancer O High Cholesterol O Heart Attack/Disease
O Other ____________________________________________________________________

Paternal Grandmother
O Diabetes O Stroke O Osteoporosis O High Blood Pressure
O Arthritis O Colon Cancer O Breast Cancer O Ovarian Cancer
O Prostate Cancer O Skin Cancer O High Cholesterol O Heart Attack/Disease
O Other ____________________________________________________________________

Maternal Grandmother
O Diabetes O Stroke O Osteoporosis O High Blood Pressure
O Arthritis O Colon Cancer O Breast Cancer O Ovarian Cancer
O Prostate Cancer O Skin Cancer O High Cholesterol O Heart Attack/Disease
O Other ____________________________________________________________________

Paternal Grandfather
O Diabetes O Stroke O Osteoporosis O High Blood Pressure
O Arthritis O Colon Cancer O Breast Cancer O Ovarian Cancer
O Prostate Cancer O Skin Cancer O High Cholesterol O Heart Attack/Disease
O Other ____________________________________________________________________
Maternal Grandfather
O Diabetes O Stroke O Osteoporosis O High Blood Pressure
O Arthritis O Colon Cancer O Breast Cancer O Ovarian Cancer
O Prostate Cancer O Skin Cancer O High Cholesterol O Heart Attack/Disease
O Other ____________________________________________________________________

Siblings Sisters: # of _________________________ brothers: # of ________________________
O Diabetes O Stroke O Osteoporosis O High Blood Pressure
O Arthritis O Colon Cancer O Breast Cancer O Ovarian Cancer
O Prostate Cancer O Skin Cancer O High Cholesterol O Heart Attack/Disease
O Other ____________________________________________________________________


Immunizations: Date(s):
Tetanus in last 10 years O Yes O No _______________________
Pneumonia O Yes O No _______________________
Hepatitis A O Yes O No _______________________
Hepatitis B O Yes O No _______________________
Chicken Pox O Yes O No _______________________
Have you had chicken pox? O Yes O No _______________________
Influenza O Yes O No _______________________
HPV vaccine O Yes O No _______________________

Prevention:
Exercise:
Do you exercise? O Yes O No
Days per week: O <3 O 3-5 O >5
Time/Duration: O <15 min O 15-30 min O 30-45 min O >45 min
Exertion: O Light O Moderate O Heavy
Review of Systems: Are you experiencing any of these issues now?
Constitutional
Fatigue O Yes O No
Weight change O Yes O No
Fever O Yes O No
Neurological
Headaches O Yes O No
Weakness O Yes O No
Dizziness O Yes O No
ENT
Vision Changes O Yes O No
Sinus Problems O Yes O No
Swallowing Problems O Yes O No
Respiratory
Shortness of Breath O Yes O No
Chronic Coughing O Yes O No
Cardiovascular
Chest Pain O Yes O No
High Blood Pressure O Yes O No
Fainting O Yes O No
Musculoskeletal
Joint Pain/Stiffness O Yes O No
Back Pain O Yes O No






Numbness/Tingling O Yes O No
Seizures O Yes O No


Hearing Changes O Yes O No
Sore Throat O Yes O No


Wheezing/Asthma O Yes O No


Irregular Heartbeat O Yes O No
Leg/Ankle Swelling O Yes O No


Joint Swelling O Yes O No
Neck Pain O Yes O No



Gastrointestinal
Nausea/Vomiting O Yes O No
Diarrhea O Yes O No
Blood in Stool O Yes O No
Skin
Rashes O Yes O No
Itching/Burning O Yes O No
Hematologic
Anemia O Yes O No
Bleeding Problem O Yes O No
Endocrine
Excessive Thirst O Yes O No
Urinary
Pain with Urination O Yes O No
Frequent Urination at night O Yes O No
Difficulty starting urinary O Yes O No
stream
Psychological
Depressed or Mood Swings O Yes O No
Sleep Disturbance O Yes O No
Anxiety O Yes O No
Gynecologic
Breast pain O Yes O No
Pain with intercourse O Yes O No
Other
Sexually Transmitted Diseases O Yes O No



Stomach Ulcer O Yes O No
Constipation O Yes O No


Skin Cancer O Yes O No
Concerning Moles O Yes O No

Easy Bruising O Yes O No


Heat/Cold Intolerance O Yes O No

Frequent Urination O Yes O No
Incontinence O Yes O No
Difficulty with strength O Yes O No
or flow rate in urine stream

Diminished Energy O Yes O No
Little interest in surroundings O Yes O No


Vaginal Discharge O Yes O No


Sexual Problems O Yes O No
(getting and keeping erections, completing intercourse, etc)
Medications (Please list name of medication and dosage)



Hospitalization (Please list) Surgeries (Please list surgery type and year)






Patient Signature ________________________________________ Date __________________
221 E Hacienda Ave., Ste B
Campbell, CA 95008
t 408.376.3350
f 408.374.4130


NOTICE OF PRIVACY PRACTICES

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical
information. We are required by law to maintain the privacy of protected health information and to provide
individuals with notice of our legal duties and privacy practices with respect to protected health information. This
notice describes how we may use and disclose your medical information. It also describes your rights and
obligations with respect to your medical information. If you have ay questions about this notice, please contact our
Privacy Officer listed on the final page.

How this Medical Practice May Use or Disclose Your Health Information

This medical practice collects health information about you and stores it in a chart and on a computer.
This is your medical record. The medical record is the property of this medical practice, but the
information in the medical record belongs to you. The law permits us to use or disclose your health
information for the following purposes:

1.Treatment. We use medical information about you to provide medical care. We disclose medical
information to our employees and others who are involved in providing the care you need. For example,
we may share your medical information with other physicians or health care providers who will provide
services which we do not provide. Or we may share this information with a pharmacist who needs it to
dispense a prescription to you, or a laboratory that performs a test. We may also disclose medical
information to members of your family or other who can help you when you are sick or injured.
2. Payment. We use and disclose medical information about you to obtain payment for the services we
have provided. For example, we give your health plan the information it requires before it will pay us. We
may also disclose information to other health care providers to assist them in obtaining payment for
services they have provided to you.
3. Health Care Operations. We may use and disclose medical information about you to operate this
medical practice. For example, we may use and disclose this information to review and improve the
quality of care we can provide, or the competence and qualifications to our professional staff. Or we may
disclose this information as necessary for medical reviews, legal services and audits, including fraud and
abuse detection and compliance programs and business planning and management. We may also share
your medical information with our business associates, such as out billing service that performs
administrative services for us. We have a written contract with each of these business associates that
contains terms requiring them to protect the confidentiality of your medical information. Although federal
law does not protect health information which is disclosed to someone other than another healthcare
provider, health plan or healthcare clearinghouse, under California law all recipients of healthcare
information are prohibited from re-disclosing it except as specifically required or permitted by law. We
may also share your information with other healthcare providers, healthcare clearinghouses or health
plans that have a relationship with you, when they request this information to help them with their quality
assessment and improvement activities, their efforts to improve health or reduce health professionals,
their training programs, their accreditation, certification or licensing activities, or their health care fraud
and abuse detection and compliance efforts.
4. Appointment Reminders. We may use and disclose medical information to contact and remind you
about appointments. If you are not home, we may leave this information on your answering machine or in
a message left with the person answering the phone.

5. Sign in Sheet. We use and disclose medical information about you by having you sign in when you
arrive at out office. We may also call out your name when we are ready to see you.
221 E Hacienda Ave., Ste B
Campbell, CA 95008
t 408.376.3350
f 408.374.4130

6. Notification and Communication with Family. We may disclose your health information to notify or
assist in notifying a family member, your professional representative or another person responsible for
your care about your location in the event of your death. In the event of a disaster, me may disclose
information to a relief organization so that they me coordinate these notification efforts. We may also
disclose information to someone who is involved in your care or helps pay for your care. If you are able
and available to agree or object, we will give you the opportunity to object prior to making these
disclosures, although we may disclose this information in a disaster even over your objection if we
believe it necessary to respond to the emergency circumstances. If you are unable or unavailable to agree
or object, our health professionals will use their best judgment in communication with family and others.
7. Marketing. We may contact you to give you information about products or services related to your
treatment, case management or care coordination, or to direct or recommend other treatments or health-
related benefits and services that may be of interest to you, or to provide you with small gifts. We may
also encourage you to purchase a product or service when we see you. We will not use or disclose your
medical information without your written authorization.
8. Required by Law. As required by law, we will use and disclose your health information, but we will
limit our use or disclosure to the relevant requirements of the law. When the law requires us to report
abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law
enforcement officials, we will further comply with the requirement set forth below concerning those
activities.
9. Public Health. We may, and are sometimes required be law to disclose your health information to
public health authorities for purposes related to: preventing or controlling disease, injury or disability;
reporting child, elder or dependent adult abuse or domestic violence; reporting to the Food and Drug
Administration problems wit products and reactions to medications; and reporting disease or infection
exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform
you or your personal representative promptly unless in out best professional judgment, we believe the
notification would place you at the risk of serious harm or would require informing a person
representative we believe is responsible for the abuse or harm.
10. Health Oversight Activities. We may, and are sometimes required by law to disclose your health
information to health oversight agencies during the course of audits, investigations, inspections, licensure
and other proceedings, subject to the limitations imposed by Federal and California Law.
11. Judicial and administrative Proceedings. We may, and are sometimes required by law to disclose
your health information in the course of any administrative or judicial proceeding to the extent expressly
authorized by a court or administrative order. We may also disclose information about you in response to
a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you
of the request and you have not objected, or if your objections have been resolved by a court or
administrative order.
12. Law enforcement. We may, and are sometimes required by law, to disclose our health information to
a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material
witness or missing person, complying with a court order, warrant, grand jury subpoena and other law
enforcement purposes.
13. Coroners. We may, and are often required by law, to disclose your health information to coroners in
connections with investigations of deaths.
14. Organ or Tissue Donation. We may disclose your health information to organizations involved in
procuring, banking or transplanting organs and tissues.
15. Public Safety. We may, and are sometimes required by law, to disclose your health information to
appropriate persons in order to prevent or lesson a serious and imminent threat to the health or safety of a
particular person or the general public.
221 E Hacienda Ave., Ste B
Campbell, CA 95008
t 408.376.3350
f 408.374.4130

16. Specialized Government Functions. We may disclose your health information for military or
national security purposes or to correctional institutions or law enforcement officers that have you in their
lawful custody.
17. Workers Compensation. We may disclose your health information as necessary to comply with
workers compensation laws. For example, to the extent your care is covered by Workers Compensation,
we will make periodic reports to your employer about your condition. We are also required by law to
report cases of occupational injury or occupational illness to the employer of Workers Compensation
insurer.
18. Change of Ownership. In the event that this medical practice is sold or merged with another
organization, your health information/records will become property of the new owner, although you will
maintain the right to request that copies of your health information be transferred to another physician or
medical group.

When This Medical Practice May Not Use or Disclose Your Health Information

Except as described in the Notice of Privacy Practices, this medical practice will not use or disclose health
information which identifies you without your written authorization. If your do authorize this medical
practice to use or disclose your heath information for another purpose, you may revoke your authorization
at any time.

Your Health Information Rights

1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain
uses and disclosures of your health information, written request specifying what information you want to
limit and what limitations on our uses or disclosure of that information you wish to have imposed.
2. Right to Request Confidential Communication. You have the right to request that you receive your
health information in a specific way or at a specific location. For example, you may ask that we send
information to a particular e-mail account or to your work address. We will comply with all reasonable
requests submitted in writing which specify how or where you wish to receive these communications.
3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with
limited exceptions. To access your medical information, you must submit a written request detailing what
information you want access to and whether you want to inspect it or get a copy of it. We will charge a
reasonable fee, as allowed by California law. We may deny your request under limited circumstances. If
we deny your request o access your childs records because we believe allowing access would reasonably
likely to cause substantial harm to your chills, you will have a right to appeal our decision. If we deny
your request to access your psychotherapy notes, you will have the right to have them transferred to
another mental health professional.
4. Right to Amend or Supplement. You have the right to request that we amend you health information
that you believe is incorrect or incomplete. You must make a request to amend in writing, and include
reasons you believe the information is inaccurate of incomplete. We are not required to change your
health information, and will provide you with information about this medical practices denial and how
you can disagree with that denial. We may deny your request if we do not have the information, if we did
not create the information (unless the person of entity that created the information is no longer available
to make the amendment), if you would not be permitted to inspect or copy the information at issue, or id
the information is inaccurate and complete as is. You also have the right to request that we add to your
record a statement of up to 250 words concerning any statement or item you believe to be incomplete or
incorrect.
5. Right to Accounting of Disclosures. You have the right to receive an accounting of disclosures of
your health information made by this medical practice, except hat this medical practice does not have to
221 E Hacienda Ave., Ste B
Campbell, CA 95008
t 408.376.3350
f 408.374.4130

account for the disclosures provided to you or pursuant to your written authorization, or as described in
paragraph 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with
family) and 16 (specialized government function) of Section A if the Notice of Privacy Practices or
disclosures for purpose of research or public health with exclude direct patient identifiers, or agency or
law enforcement official to the extent this medical practice has received notice from that agency or
official that is providing this accounting would reasonably likely to impede their activities.

If you would like to have more detailed explanation of these rights or if you would like to exercise one or
more of these rights, contact our Privacy Officer.

Changes to this Notice of Privacy Practices

We reserve the right to amend this Notice of Privacy Practices at any time in the future, Until such
amendment us made, we are required by law to comply with this Notice. After an amendment is
made, the revised Notice of Privacy Protections will apply to all protected health information that
we maintain, regardless of when it was created or received. We will keep a copy of the current
notice posted in out reception area and will offer you a copy at each appointment. We will also post
the current notice on out website.

Complaints

Complaints about this Notice of Privacy Practices or how this medical practice handles your health
information should be directed to our Privacy Officer.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal
complaint to:

Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Building
200 Independence Avenue. SW
Room 509 F HHH Building
Washington, DC 20201

You will not be penalized for filing a complaint
221 E Hacienda Ave., Ste B
Campbell, CA 95008
t 408.376.3350
f 408.374.4130

Notice of Privacy Practices

Privacy Officer: Tiffany Gorman, M.D.
Effective Date: April 15, 2003




I hereby acknowledge that I received or reviewed a copy of this medical practice
Notice of Privacy Practices.

I further acknowledge that a copy of the current notice will be available in the
reception area and that I will be offered a copy of any amended Notice of
Privacy Practices if there are any changes.

Signed_____________________________________ Date_____________

Print Name__________________________________ Phone___________

If not signed by the patient, please indicate relationship:

_____ Parent or guardian of minor patient

_____ Guardian or conservator of incompetent patient

221 E Hacienda Ave., Ste B
Campbell, CA 95008
t 408.376.3350
f 408.374.4130

Office Policies

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Welcome to the office of Silicon Valley Sports Medicine. Please read and sign our office policies that includes a waiver
we need in order to bill your insurance company. If you have any questions, please inquire at the front desk.


_____ Contracted insurance companies: We will be happy to bill to them, provided that you have submitted complete and current insurance
information to us. Insurance companies now mandate a 90-day billing period. Therefore, we will not bill nor re-bill any insurance claims
after 90 days should your insurance information be incorrect. All balances on your account will be due and payable immediately by you. If
for any reason your insurance company does not pay for your visit, it is your responsibility to pay for the office visit.

_____ Copayments are due at the time of visit! Your insurance contract states explicitly that a co-pay is due at the time of services
rendered. Your appointment (for non-emergencies) may be rescheduled if you do not bring your co-pay with you to your appointment.

_____ Patient balances: All patient balances are due and payable at the time of your office visit. If you do not pay your balance in a timely
manner then you will be subjected to finance charges and sent to a collection agency. If you are sent to a collection agency, you will be
discharged from our practice. As a reminder, all bounced checks will be charged a $25 fee.

_____ Cancellation policy: We have a 24 hour cancellation policy. If you give less than 24 hours notice or do not show for your scheduled
appointment, you will be assessed a $40 fee.

Prescriptions: We do not prescribe medications over the telephone or in response to emails. It is in your best interest to be examined to
assure that the proper medications (if necessary) are administered. If your prescription needs to be refilled, please make the request
directly to your pharmacy. They will contact us and this will ensure that all pertinent information is included. Please allow a minimum of
48 hours for prescription refills. Our office is closed on weekends and most holidays; the on call physicians will NOT do medication refills.

Physical Exams: Physicals are considered routine maintenance and may or may not be a covered benefit by your insurance company. It
is always a good idea to know in advance what benefits your insurance provides. This exam is for healthy individuals who need age
specific screening performed, i.e. routine blood work, pap smears, breast exams, prostate exams, etc. Since these visits require a longer
visit, we are only able to accommodate several a day and can often have a several month waiting period. Please consider scheduling in
advance.

My insurance covers routine maintenance physicals and immunizations:
___ Yes
___ No
___ Not Sure, but I accept financial responsibility if not covered

Lab work, pap smears and biopsies: These services will be billed directly to you by the lab. There is a separate fee from the
pathologist for reading and interpreting your results. Please submit current and complete insurance information to ensure proper billing.
Test results are available online by accessing our patient portal. It is imperative you know what your results are. Please contact the office
if you are unable to login to the patient portal successfully

Medical records: Should you need to transfer your medical records you will be charged a $30 fee. Since we use electronic medical
records this information will be supplied to you or the requesting physician on a disc.

Patient Portal: Online access to our practice is available through our Patient Portal, which enables you to communicate with our practice
easily, safely, and securely over the Internet. In addition to messaging the office, you can request and keep track of appointments,
request and view lab results, request prescription refills, view your personal health record, view billing statements and view and request
referrals.


My signature below indicates that I have read and understand the policies of this office and agree to comply with them.

I authorize Silicon Valley Sports Medicine to release to my insurance carrier and their agents any information needed to determine the benefits
payable under their coverage. I further authorize my insurance company to disclose to the doctors any information requested regarding claims for
medical benefits. A copy of this authorization may be used in place of the original. I request that payment of authorized medical benefits be made
on my behalf to Silicon Valley Sports Medicine for services rendered.


________________________________ _________________________________ ______________
Name Signature Date
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