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941-365-1321 | PATIENT PORTAL
Concierge Medical Services
  • Home
  • About
    • Dr. Bart Price
    • Dr. Petra Travnicek
    • CMS Staff
  • Our Program
    • FAQs
  • Patient Forms
    • New Patient Package
    • Medical Records Release
    • Membership Agreement
    • Annual Exam
    • Bi-Annual Exam
    • COVID-19 Informed Consent
  • Contact
  • Patient Portal

New Patient Packet

Step 1 of 16

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  • Patient Information

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  • Person who will act as your healthcare advocate if there is a need.
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    Upload a signed copy of your DNR.
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  • Insurance and Financial Agreement

  • I request that payment of authorized Medicare/Other insurance company benefits be made to Manasota Medical Group, LLC for any services furnished to me. Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carries any information needed for this or a related Medicare/Other insurance company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be paying for my treatment. (Section 1128B of the Social Security Act and 31 USC 3801-3812 provides penalties for withholding this information.)
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  • MM slash DD slash YYYY
  • INSURANCE PRE-CERTIFICATION:
    I understand that I am responsible for any required notification needed by my insurance company in order to pay for services rendered. If this is not done, my benefits may be reduced and I am responsible for all non-covered charges.

    ASSIGNMENT OF BENEFITS:
    I hereby assign to Manasota Medical Group any and all benefits from my insurance plans or any other protection maintained by the patient. I authorize and direct such benefits to be paid directly to Manasota Medical Group, for
    services provided. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days of filing, I authorize Manasota Medical Group to file a complaint to the Insurance Commissioner in order to reimburse their offices.

    FINANCIAL AGREEMENT:
    The undersigned guarantees prompt payment of all charges for services rendered at time of service. Any unpaid balance due by patient beyond 30 days may be turned over for collection.

    CONSENT FOR MEDICAL SERVICES:
    I consent to treatment, diagnostic, and / or therapeutic services as ordered and / or provided by Manasota Medical Group.

    CANCELLATION POLICY:
    I understand there is a 24 hour notice to cancel an appointment and that I may be charged for canceling an appointment without notice.
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  • MM slash DD slash YYYY
  • Current Medications / Vitamins / Supplements / Herbs

  • Prescriptions
  • Name of MedicationStrengthFrequency 

    Click "+" to list more medications

  • Food or Drug Allergies

  • AllergyReaction 
  • Tests & Services

  • Please list the Most Recent date you had any of these tests / services
  • Other Physicians

  • Past Personal Medical History

    Please check all that apply
  • Hypertension

  • Diabetes

  • Angina

  • Heart Attack

  • Rheumatic Fever

  • Valvular Disease

  • Mitral Valve Prolapse

  • Congestive Heart Failure

  • Pulmonary Edema

  • Irregular Rhythm

  • Atrial Fibrillation

  • Pacemaker

  • Asthma

  • Chronic Bronchitis

  • Emphysema (COPD)

  • Pneumonia

  • High Cholesterol

  • Cancer

  • Stroke

  • TIA

  • COVID-19

  • Cataracts

  • Lenses

  • Glasses

  • Glaucoma

    Please check all that apply
  • Visual Loss

  • Diabetic Retinopathy

  • Macular Degeneration

  • Color Blind

  • Hearing Loss

  • Chronic Headaches

  • Migraines

  • Seizure Disorder

  • Fainting Spells

  • Loss of Consciousness

  • Obesity

  • Eating Disorder

  • Environmental Allergies

  • Dental Problems

  • Neck Problems

  • Thyroid Disease

  • Hiatal Hernia

  • Reflux Disease (GERD)

  • Peptic Ulcer

  • Bleeding Ulcer

  • H. Pylori

  • Gastritis

  • IBS

  • Chronic Diarrhea

  • Chronic Constipation

  • Diverticulosis

  • Diverticulitis

  • Crohn’s

  • Colitis

  • Ileitis

    Please check all that apply
  • Hemorrhoids

  • Abnormal Liver Function

  • Hepatitis

  • Cirrhosis

  • Gallbladder Disease

  • Pancreatitis

  • Osteoarthritis

  • Rheumatoid Arthritis

  • Disc Disease

  • Fractures

  • Spinal Stenosis

  • Osteoporosis

  • Osteoarthritis

  • Motor Vehicle Accident

  • Work Accident

  • Seat Belt Use - % of time

  • Anemia

  • Lymphoma

  • White Blood Cell Disorder

  • Impaired Immunity

  • Abn. Bleeding Tendencies

  • Coumadin Use

  • Abn. Kidney Function

  • Kidney Stones

  • Kidney / Bladder Infections

  • Incontinence

  • Skin Cancer

    Please check all that apply
  • Eczema

  • Psoriasis

  • Seborrhea

  • Hair / Nail Disorders

  • Sexual Dysfunction

  • Infertility

  • Positive TB Test

  • Herpes

  • History of STDs

  • Lyme Disease

  • Chronic Fatigue Syndrome

  • HIV

  • Memory Disturbances

  • Parkinson’s Disease

  • Neuropathy

  • Multiple Sclerosis

  • Tremors

  • Balance Problems

  • Muscle Spasms

  • Restless Leg Syndrome

  • Tendonitis

  • Polymyalgia

  • Gout

  • Any Prosthetic Devices

  • Insomnia

  • Sleep Disorder

    Please check all that apply
  • Sleep Apnea

  • History of Radiation

  • Learning Disability

  • Dyslexia

  • ADD / ADHD

  • Anxiety

  • Depression

  • Phobias

  • Manic Depression

  • Bipolar Disorder

  • OCD

  • Adjustment Reactions

  • Suicide Attempts

  • History of Physical Abuse

  • History of Emotional Abuse

  • Past or Present Addictions

    Please check all that apply
  • Brain

  • Eyes - Cataracts

  • Sinus

  • Nasal

  • Ear

  • Tonsils

  • Neck

  • Breast-Biopsy

  • Lumpectomy

  • Mastectomy

  • Heart-Bypass

  • Balloon Angioplasty

  • Stents

  • Valves

  • Lung

  • Chest

  • Abdominal-Hernia Repair

  • Appendectomy

  • Gallbladder

  • Stomach

  • Bowel

  • Hemorrhoids

  • Childbirth(s)

  • Pregnancies

  • Hysterectomy

  • Removal of Ovaries

  • Tubal Ligation

  • Kidney

  • Kidney Stones

  • Bladder

  • Prostate

  • Vasectomy

  • Hip Replacement

  • Knee Replacement

  • Joint Replacement

  • Back

  • Disc

  • Cosmetic

  • Carpal Tunnel

  • Aneurysm Repair

  • Varicose Veins

  • Skin

  • Lasik Surgery

  • Other

  • Surgery TypeYearAdditional Comments 
  • Review of Body Systems

  • Family History: Genetic & Acquired Predispositions

  • Heart Disease

  • Cancer

  • Diabetes

  • Hypertension

  • Cholesterol

  • Adult Immunization History

  • Consumption

  • Nutrition Survey

  • Use of Complimentary Alternative Medicine

  • Accident Prevention & Auto Safety

  • Exercise Habits

  • TypeFrequency 
  • Sleep

  • Social History

  • Packet Confirmation

  • MM slash DD slash YYYY
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  • The Burns Depression Inventory

  • The Epworth Sleepiness Scale

  • This field is for validation purposes and should be left unchanged.

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Sarasota, FL 34239

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