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 *

Registration Complete!

Thank you. Your forms have been securely submitted.

Location -

What happens next?
Our team will review your information and contact you shortly to schedule your appointment.

Return to Website

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)

Registration Complete!