New Patient Registration | Vally Medical Group

Patient Information

Full Name *

Birthdate *

Gender *

Social Security Number

Phone (Home)

Phone (Cell) *

Email

Mailing Address

Physical Address

Emergency Contact

Name

Relationship

Phone

Email

OK to release information to this contact?

Injury Information

Type of Injury *

Work Personal Injury Auto

Date of Injury *

What are your injured body parts?

How did this injury occur? *

Were you seen at an Urgent Care or Hospital?

Yes No

Workers' Compensation

Is this a Workers' Compensation claim? *

Yes No

Have you been seen by another Facility/Physician for this injury?

Yes No

Employment Information

Name of Employer

Job Title

Supervisor Name

Supervisor Title

Employer Phone

Employer Fax

Employer Email

Days worked per week

Hours worked per day

Duration of Employment

Physical Work Requirements

Work Environment

Was any PPE worn?

Yes No

Exposed to Dust/Fumes/Gas?

Yes No

Moving Machinery?

Yes No

Currently Employed?

Yes No

Zero Tolerance Policy

Notice to all patients:

Please be advised that Vally Medical Group has adopted a zero-tolerance policy.

"Our providers and staff will not tolerate any disrespectful, rude, aggressive or abusive behaviors in any way."

As your provider, our staff is working endlessly to provide the best care possible. Any person behaving in an abusive and disrespectful manner will be discharged immediately.

- Zain Vally Mahomed, MD

I have read and agree to the Zero Tolerance Policy. *

Cancellation Policy

Due to an increase in "No-shows" and late cancellations we will be charging a $35.00 fee for any person not arriving by your scheduled appointment time. There is no grace period.

Failure to cancel 24 hours prior to a scheduled appointment will result in this fee, which is the responsibility of the patient, not the insurance company.

I have read and agree to the $35 Cancellation/No-Show Policy. *

Patient Acknowledgment & Signature

Patient Signature (Type Full Name) *

Date *

By typing your name above, you acknowledge that all information provided is true and correct to the best of your knowledge, and that you agree to all policies listed above.

Medications & Allergies

List any medications you currently take and any drug allergies

Current Medications

Example: Atorvastatin / 20mg / Once a day

Medication Name

Dosage

Frequency

Leave blank if you don't take any medications.

Drug Allergies

Do you have any drug allergies? *

No Yes

Medical Records Release

Authorization for Use or Disclosure of Health Information

First Name *

Last Name *

Former Name

Date of Birth *

Mailing Address

Home Phone

Cell Phone *

Exchange Information With:

Name of Person / Facility *

Address

Phone

Email

Fax

Release To/From:

Vally Medical Group

82 Pu'uhonu Place #202-203, Hilo, HI 96720

P: (808) 935-6353 | F: (888) 511-6031

I acknowledge records may include info on physical illness, alcohol/drug abuse, or HIV/AIDS. * I understand info disclosed may be re-disclosed by recipient and no longer protected. * I understand my info is protected by regulations and requires written authorization. *

Designation of Representative

Optional

Would you like to authorize someone else (spouse, family member, etc.) to receive your health information?

No, skip this Yes, add representative(s)

Signature (Type Name) *

Date *

Informed Consent to Treat

Please review and sign below

I, [Patient Name], AUTHORIZE Vally Medical Group, Dr. Zain Vally-Mahomed, MD and Crystal Castillo, FNP to use AI and scribe services and to perform the following procedures as necessary to facilitate my diagnosis and treatment:

Diagnostic Procedures
Minor office procedures
Prescribe Medications
Medical Injections
Hyperbaric Oxygen Chamber Therapy

I recognize the risks and benefits of these procedures as described below:

Potential Risks: Allergic reactions to prescribed medications, herbs and supplements, side effects of medications, inconvenience of lifestyle changes, injury or death from complications involving injections, venipuncture and/or in-office procedures.

Potential Benefits: Restoration of health and the body's maximal functional capacity, relief of pain and symptoms, assistance in injury and recovery, prevention of disease and injury progression.

Notice to Pregnant Women: All female patients must alert the medical provider if they know or suspect that they are or may be pregnant, as some medications, procedures, or therapies could present a risk to the pregnancy.

Acknowledgments

With this knowledge, I voluntarily consent to the above procedures, knowing that no guarantees have been given to me by Vally Medical Group or any of its personnel regarding a cure or improvement of my injury(s) and/or my condition.

I understand that a record will be kept of the health services provided to me. These records will be kept confidential and will only be released if directed by myself or my representative unless it is required by law.

I understand that medical records will be kept for a minimum of three years. I understand that information from my medical records may be analyzed for research purposes, and that my identity will be kept confidential.

I understand that any questions I have will be answered by my provider to the best of his/her ability.

I have read, understand, and agree to all of the above statements. I voluntarily consent to examination and treatment. *

Electronic Signature

By typing your full legal name below, you are electronically signing this consent form with the same legal effect as a handwritten signature.

Patient Signature (Type Full Name) *

Date *

Registration Complete!

Thank you. Your forms have been securely submitted.

Location -

What happens next?
Our team will verify your insurance eligibility and contact you to schedule your appointment. Please note that Vally Medical Group accepts Workers' Compensation and OWCP insurance only. If you have questions, call us at (808) 935-6353.

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Vally Medical Group

Welcome, New Patient!

Patient Intake Form

Medications & Allergies

Records Release

Patient Information

Emergency Contact

Injury Information

Workers' Compensation

Adjuster Information

Employment Information

Physical Work Requirements

Work Environment

Zero Tolerance Policy

Cancellation Policy

Patient Acknowledgment & Signature

Medications & Allergies

Current Medications

Drug Allergies

Medical Records Release

Exchange Information With:

Release To/From:

Designation of Representative

Representative #1

Representative #2 (Optional)

Informed Consent to Treat

Acknowledgments

Electronic Signature

Registration Complete!