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956-292-0100
EDINBURG, JACKSON, SOUTH MCALLEN
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ASAS HEALTH. Monzer H Yazji, M.D
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Home
About Us
Patient Orientation
Service Policies
Forms
Worker’s Comp
After Hours Care
House Calls/Home Visits
Hospital Care
Community Resources
Emergencies
Survey
Our Medical Staff
Quality Improvement
Medical Home
Preceptorship
The Star Program
Contact Us
New Patient Form
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New Patient Form
Personal Information
Last Name
*
First Name
*
M.I
*
Street Address
*
Apt. #
*
City
*
State
*
ZIP Code
*
Home Phone
*
Cell
*
S.S #
*
Is this visit due to a work related injury ?
Yes
No
Date of Accident:
EMERGENCY CONTACT INFORMATION
Emergency Contact Name
*
Phone
*
Work Phone
*
Emergency Contact Name
Phone
Work Phone
Please Select an answer for each question.
What is your RACIAL background?
*
American
Anglo-Saxon
Arab
Asian
Black
Black Non-Hispanic
Caucasian
East India
Hispanic
Indian
Latin American
Latino
Mexican
Mexican American
Native American
Pakistani
Polish
White
White Non- Hispanic
Patient Refuses
Other Race or Ethnicity
Other Race or Ethnicity
What is your ETHNIC background?
*
American
American Indian
Anglo
Buddist
Caucasian
Czeck
Egyptian
French
German
German-American
Greek
Hispanic
India
Latin American
Latino
Mexican
Mexican American
Northern European
Pakistani
Phillipina
Polish-American
Puerto Rican
White
Not Reported/Refused
Other
Patient Refused
What is your language of choice ?
*
English
Spanish
Other
Upload Your Signature Below
Your signature below indicates your consent for the treatment of/as patient and the release of medical information to your insurance company for claim purposes. I understand/acknowledge that any service charges which are deemed medically unnecessary or inappropriate by my insurance company will be paid directly by me.
Your Signature Image format
Date
ACKNOWLEDGMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICE
I have reviewed this practice's Notice of Privacy Practices,
which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
Patient’s Signature or Personal Representative
*
Date
*
Name of Patient or Personal Representative
*
Personal Representative Relationship to Patient
*
VOICE MESSAGE CONSENT FORM
Fill the field with your full name
*
, hereby Authorize / Refuse (circle one) Monzer H. Yazji, M.D. & Associates
to utilize my voice answering service to transmit information related to my health care needs. I fully understand that these messages could range from simple appointment reminders to elaborate physician instructions.
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