Patient Registration FormLast Name First Name M.I. DOB

Home Phone ( ) Cell Phone ( ) ER Phone ( )

Emergency Contact Phone ( )

Marital Status Married Single Divorced Separated Widowed Sex M F

E-mail Address

Race (optional) Ethnicity (optional) Language (optional)

Primary Care Physician Student: FT PT Previous Name

Employer Name Employer Phone ( )

Employer Address

Guarantor Information (If different than the Patient)

Last Name First Name M.I.

Address City State Zip Code

Home Phone ( )

Primary Insurance Information (Please present Insurance Card at Reception Desk)

Insurance Eff Date Name Insurance Carrier Group ID # Policy ID #

Insurance Address City State Zip Code

Relationship of Patient to Subscriber Self Spouse Child Other (Explain)

Subscriber DOB Subscriber SS# Sex M F

Subscriber Employer Name Employment Phone ( )

Employer Address City State Zip Code

Secondary Insurance InformationInsurance Eff Date Name Insurance Carrier Group ID # Policy ID #

Insurance Address City State Zip Code

Relationship of Patient to Subscriber Self Spouse Child Other (Explain)

Subscriber DOB Subscriber SS# Sex M F

Subscriber Employer Name Employment Phone ( )

Employer Address City State Zip Code

By signing this form, I hereby authorize and request payment of medical benefits for services and/or supplies rendered to me be paid directly to ARIZONA COMMUNITY PHYSICIANS, P.C. or its authorized representative. I authorize release of any medical record or other information necessary to process claims, related to such services, to government benefit programs or other medical insurance payers. I further permit a copy of this authorization to be used in place of the original. By signing, I understand that regardless of any available insurance plan or program, I am financially responsible for any incurred charges. The effective period of this authorization is from today’s date to a future date, when I am no longer a patient of the Arizona Community Physicians, P.C. group or am deceased.

PATIENT OR GUARDIAN SIGNATURE DATE

Arizona Community Physicians6130 N. La Cholla Blvd, Suite 100, Tucson, Arizona 85741 Phone 520-742-4159

LACH-127 REV. 7/13

Arizona Community Physicans, P.C.

No Show PolicyOur goal is to provide quality medical care on a timely manner. In order to do so we have to implement an appointment cancellation policy. The policy enables us to better utilize available appointments for our patients in need of medical care.

A patient who does NOT SHOW for their appointments and who does not notify the office 24 hours in advance, may be charged an administrative fee of $25. This fee is not payable by any insurance company, and remains the responsibility of the patient. This is due in full prior to your next appointment. We ask that you please call 24 hours in advance to 742-4159 if you are unable to keep your appointment.

PrescriptionsPrescription refills: Call your pharmacy for refills on medications. Please allow 48 hours for a prescription to be refilled. If you have not had an appointment within a year you may need tohave an appointment before we refill your medication.

Narcotic prescriptions (pain pills, sleeping pills, nerve pills and muscle relaxers): We will not fill onFridays. If you need a prescription that requires a physician to write the prescription andan original signature, that will be handled Monday thru Thursday. You will be required tocome to the office to pick up the prescription.

Forms Completion FeesThere are fees charged for completing forms. They are not covered by insurance and are the responsibility of the patient.There are many different types of forms and are as diverse as the institution requesting the form. It may not be possible to determine what fee will apply to the form until the physician reviews it. The cost could range from $10-200 in most cases. We will call you to get approval for any form completion with a charge more than $50.

I have read and acknowledge the above information.

LACH-131 REV. 4/13

Signature Date

MRN#______________

Arizona Community Physicians

Drs. Carter, Rothe, Lowry, Hee, & Haase

Adult Health Questionnaire

Page 1

Patient name:

DOB:

Constitutional

Eyes

Ears, Nose, and Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

For Females

MRN

Date:

YES NO Comments

A: Recent weight change?B: Fevers, Chills, or Night sweats?C: Fatigue?

A: Diffi culty seeing?B: Contact lenses or glasses?C: Temporary loss of vision?

A: Problems with hearing?B: Hoarseness, sore throat, or trouble swallowing?C: Nose Bleeds?

A: History of murmurs?B: Chest pain?C: Known heart rhythm problems?

A: Cough?B: Shortness of Breath?C: Wheezing or asthma symptoms?D: Coughing up blood?

A: Constipation or Diarrhea?B: Abdominal pain?C: Recent change in appetite?D: Blood in stool?E: Heart burn?F: Nausea or vomiting?

A: Frequent urination? Trouble urinating?B: Incontinence?C: Blood in urine?D: Painful urination?

Last menstrual period?Birth control method?A: Vaginal discharge?B: Irregular or painful menses?C: Bleeding after menopause?

LACH-138-1

Arizona Community Physicians

Drs. Carter, Rothe, Lowry, Hee, & Haase

Adult Health Questionnaire

Page 2

Patient name:

DOB:

Genitourinary continued

For Males

Musculoskeletal

Skin

Neurologic

Psychiatric

Endocrine

Hematology/Lymphatics

Breast

YES NO Comments

A: Diffi culty obtaining an erection?B: Diffi culty with urine stream?

A: Joint pain or swelling?B: Calf or leg pain with walking?C: cold extremities?

A: Rashes?B: Skin cancers?C: Other skin issues?

A: Minor stroke?B: Recent numbness or tingling?C: History of seizures?D: Extremity weakness?

A: Depression?B: Anxiety?C: Other psychiatric disorders?

A: History of high or low blood sugar?B: Heat or cold intolerance?C: Thyroid problems?

A: Easy bruising?B: Swelling in legs?C: Anemia?D: Enlarged nodes or glands?

A: Pain?B: Nipple discharge?C: Other changes or abnormalities?

LACH-138-2

LACH-102-1 7/14

PERSONAL MEDICAL HISTORY MRN:__________________

(admin use only )

____________ ______________________________________ ________________ _________ Date Name Birthdate Age Which medical provider are you seeing today? ___ Dr. Carter ___ Dr. Rothe ___ Dr. Lowry ___ Sue Medlen, FNP ___ Dr. Hee ___ Dr. Haase ___ Amy Brunsvold, FNP ___ Neal Bohnsack, FNP Who referred you to our office? ________________________________________________ What is the main reason for your visit today?______________________________________________

Please list your medications, include dosage and number per day:

Medication Dose Frequency (x per day) 1. __________________________________________________ _____________ ________________________

2. __________________________________________________ _____________ ________________________

3. __________________________________________________ _____________ ________________________

4. __________________________________________________ _____________ ________________________

5. __________________________________________________ _____________ ________________________

6. __________________________________________________ _____________ ________________________

7. __________________________________________________ _____________ ________________________

8. __________________________________________________ _____________ ________________________

9. __________________________________________________ _____________ ________________________

10__________________________________________________ _____________ ________________________

Are you currently taking any of the following nonprescription medications? Aspirin?____ Ibuprofen?_____ Tylenol?_____ Allergy Medication?_____ Laxatives?_____

Vitamins or Supplements? _____________________________________________________________

Please list any medications you are allergic to and the reaction: Medication Reaction 1. ________________________________ _____________________________________________

2_________________________________ _____________________________________________

3.________________________________ _____________________________________________

Are you on a special or modified diet?____________________________________________________

Preferred Pharmacy and Location? _____________________________________________________________ Mail Order Pharmacy? __________________________________________________________________

LACH-102-2 7/14

What is/was your occupation? ___________________________ Spouse?_____________________________

Marital status? M-S-W-D_____ Education? High School/GED___ College____ Other____

Do you use tobacco? Yes___ If so, how much?_____ No____ Ex-smoker, quit in year _________ Do you drink alcohol? Yes____ No____ Do you exercise? Yes____ No____ What?_____________

List Illness or operations requiring hospitalization and year of problem: 1. __________________________________________________________________________

2. __________________________________________________________________________

3. __________________________________________________________________________

4. __________________________________________________________________________

5. __________________________________________________________________________

6. __________________________________________________________________________

7. __________________________________________________________________________

8. __________________________________________________________________________

9. __________________________________________________________________________

Please indicate the year you may have had the following tests or vaccinations: Physical exam _____ Pap Smear _____ Mammogram _____ Bone density/Dexa ______

Colonoscopy _____ PSA/prostate _____ EKG ______ Cholesterol ______ Audiogram/hearing test _____

Vaccines: Tetanus _____ Shingles _____ Pneumonia _____Other vaccines ______________________

FAMILY HISTORY

Who in family had?

Father Mother Grandparent Brothers Sisters

Diabetes

High Blood Pressure

Cancer (type)

Heart Attack before age of 60

Stroke before age of 60

Asthma

Colon Polyps

Other (specify)

Please list other physicians you have seen in the last two years and reason:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

6130 N. La ChollaSuite 100

Northwest ACPImaging Center

2191 W.Orange Grove Rd.

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Tangerine Road

Ina Road

Orange Grove Road

River Road

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Drs. Carter, Rothe, Lowry, Hee & Haase Family PracticeDorota Pucyk M.D., Endocrinologist

Nurse Practitioners: Sue Medlen, Neal Bohnsack & Amy Brunsvoldon the campus of Northwest Medical Center

6130 N. La Cholla Blvd., Suite 100, Tucson, AZ 85741Phone: (520) 742-4159 Fax: (520) 575-1306

River Road

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Drs. Carter, Rothe, Lowry, Hee & HaaseFamily Practice

W. ORANGE GROVE RD.

Enlarged Building View

Parking

Entrance

Suite 100

To W. Ina Rd.

To N. Oracle Rd.

Dorota Pucyk M.D., EndocrinologistNurse Practitioners: Sue Medlen, Neal Bohnsack & Amy Brunsvold

on the campus of Northwest Medical Center

6130 N. La Cholla Blvd., Suite 100, Tucson, AZ 85741Phone: (520) 742-4159 Fax: (520) 575-1306

N. L

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SonoraBehavioral

Health Hospital6050 N.

Corona Rd.

TheWomen’s

Center

1920 W.Rudasill Rd.

The Fountainsat La Cholla

2001 W.Rudasill Rd.

Desert Cardiology6130 N. La Cholla Blvd.

AZ Oncology/Urology2070 W. Rudasill Rd.

NorthwestProfessional Bldg.

2055 W. Hospital Dr.

HealthSouthRehabillitation

Hospital1921 W.

Hospital Dr.

Desert LifeMedical Buildings

2001 W. Orange Grove Rd.

PACU/Surgery

NorthwestMedical Plaza

NorthwestMedicalCenter

ER/ Outpatient6200 N. La Cholla

Blvd.

Desert LifeRehabilitation

and Care Center1919 W.

Medical St.

NorthwestMedical Park

1845 W. Orange Grove Rd.

ArizonaOncology

Orange GroveMedical Office Bldg.

1925 W. Orange Grove Rd.

402-416

504-508

302-312

602-612

202-260

102-112

Radiology Ltd.

ParkingGarage

La Cholla Medical Plaza

Northwest Tucson Surgery Center

6320 N. La ChollaBlvd.

Entrance

RillitoNursery

Valero Corner Store

Carondelet

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6130 N. La Cholla Blvd.

Walgreens

To W. River Rd.

Carter, Rothe, Lowry, Hee & Haase

Life Care Center

J2 Lab

Western Arizona

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LACH-104 Rev. 2/15

LACH-112 7/14

John Z. Carter, MD Thomas C. Rothe, MD Harold D. Lowry, MD Darren P. Hee, MD Loan P. Haase, MD Sue Medlen, RN, FNP Amy N. Brunsvold, FNP Neal P. Bohnsack, FNP

Affiliated with Arizona Community Physicians

6130 N. LaCholla Blvd. Suite 100 Tucson, AZ 85741

Telephone: (520) 742-4159 Fax: (520) 575-1306 Patient: Date: Address: Appointment Date and Time: We are pleased to welcome you as a new patient in our office. Please arrive about 20 minutes early to familiarize yourself with our location and to allow us time to add/update you in our computer system. Please complete the enclosed “Initial Medical History Form” prior to your visit. These appointments are often scheduled months ahead of time. If you need to cancel or reschedule, please let us know IMMEDIATELY. The purpose of this visit is to “get acquainted” and is scheduled to last about 15-20 minutes. It is NOT a complete physical exam but intended to address your primary medical concerns. We will be happy to renew prescriptions (please bring in your bottles) and deal with your health issues in the time allotted. We may indeed want you to schedule a follow up visit or a complete physical exam but will determine this after assessing your needs. The following is a checklist of things to do or bring for your visit: _________ Yourself, 20 minutes early for computer updating and insurance verification _________ Completed “Initial Medical History Form” _________ Current insurance cards/information (VERY IMPORTANT) _________ Bottles/list of medications to be filled or renewed _________ We likely will need medical records from your previous physician. We ask that you bring the name and address of the physician(s) who have the most significant medical records. We will have you fill out a “Release of Records Form(s)” in the office to obtain the records. These can take up to a month or more to arrive at our office. We look forward to meeting you soon and assisting in your medical care. __________________________________ Receptionist for _________________________________