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847-882-1438
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Providers
Dr. Sameer M. Naseeruddin MD
Sejal Jhaveri FNP-BC
Dr. Jaini Mody MD
Dr. Matt Zawilenski MD
Gabriela Vega-Garcia, MSN, FNP-BC
Primary Care
Physicals Schaumburg & Annual Check-ups Specialist
Hypertension Schaumburg
Diabetes Schaumburg
Back Pain Schaumburg
Medical Weight Loss Schaumburg
Immigration Medical Exam Chicago
Worker’s Compensation Specialist
Varicose Vein Specialist
Skin & Acne
Acne
Acne Scarring
Photodynamic Therapy
Hyperpigmentation
Aesthetics
Telemedicine
Schedule a Covid Test
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Patient Portal
Patient Forms
Medical Center Videos
Medical Center Promotions
Vein Treatment Questions
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Corporate Wellness
Providers
Dr. Sameer M. Naseeruddin MD
Sejal Jhaveri FNP-BC
Dr. Jaini Mody MD
Dr. Matt Zawilenski MD
Gabriela Vega-Garcia, MSN, FNP-BC
Primary Care
Physicals Schaumburg & Annual Check-ups Specialist
Hypertension Schaumburg
Diabetes Schaumburg
Back Pain Schaumburg
Medical Weight Loss Schaumburg
Immigration Medical Exam Chicago
Worker’s Compensation Specialist
Varicose Vein Specialist
Skin & Acne
Acne
Acne Scarring
Photodynamic Therapy
Hyperpigmentation
Aesthetics
Telemedicine
Schedule a Covid Test
Resources
Patient Portal
Patient Forms
Medical Center Videos
Medical Center Promotions
Vein Treatment Questions
Gallery
Media
Testimonials
Affiliates
Contact
Services
Corporate Wellness
Patient Forms
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Patient Forms
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Name
*
First
Last
DOB
*
Date Format: MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Cell Phone
Would you like to receive text messages?
Yes
No
Email
*
Would you like Portal Access?
*
Yes
No
Portal Access: Skypoint Medical Center is pleased to provide you with online access to your health information through our Patient Portal. Here you can view and create new appointments with our practice, exchange secure messages with our staff, update your contact information and insurance, read and print important forms, and access lab results and the latest data on Health . If you want to access an email will be sent to you.
Ethnicity
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Latino/Hispano
Other
Maritial Status
*
M
S
S
W
Languages
*
Emergency Contact
Emergency Contact Name
*
First
Last
Emergency Contact Relationship
*
Emergency Contact Phone
*
How did you hear about the office?
Name of Primary
*
First
Last
Relationship
DOB
Date Format: MM slash DD slash YYYY
Type of insurance
*
PPO
HMO
Insurance Type
*
BCBS
Cigna
Humana
UHC
Medicare
Medicaid
Workers Comp/Motor Vehicle Cases
Date of injury
Date Format: MM slash DD slash YYYY
Claim Number
Adjuster Name
Adjuster Phone
Insurance Name
Insurance Phone
Attorney Name
Attorney Phone
Medical History
Have you ever had any of the following?
*
Heart Disease
Heart Murmur
Rheumatic Fever
Asthma
Pneumonia
High Blood Pressure
Anemia
Connective Tissue Disease
Sickle Cell Disease
Blood Transfusion
High Cholesrterol
Diabetes
Cancer
Migrains
Congenital Disease
Seizures
Epilepsy
Liver Disease
Hepatitis
Mononucleosis
Gall Bladder Disease
Kidney Problems
Mood Disorders
STDs
Rubella
Genetic Condition
Overweight
Drug Abuse
Other
Cancer: What Type?
*
Other:
*
Do you ever experience any of the following regularly?
*
Chest Pain
Shortness of Breath
Vision Problems
Dizziness
Headaches
Sensory Difficulties
Pain
Have you been admitted to the hospital?
*
Yes
No
Date of Admission
*
Date Format: MM slash DD slash YYYY
Hospital Name
*
Reason
*
Family History
Do any of the following conditions run in your family?
*
Stroke
Heart Attack
High Cholesterol
High Blood Pressure
Cancer
Diabetes
Genetic Condition
Breast Cancer
Cancer: What type?
*
Social History
Do you smoke?
*
Yes
No
How many per day?
*
Do you drink alcohol?
*
Yes
No
How many times per weeks?
*
Use illegal drugs?
*
Yes
No
If Yes, Which ones?
*
Medication/Allergies
Medication/Dosage
Please list any medications that are being taken.
Allergies
Please list any allergies.
To ensure that each patient is given the proper amount of time allotted to their visit and to provide the high quality of care that you deserve, it is very important that all scheduled patients arrive on time. Appointment cards are provided at the time of scheduling and reminder calls are made/attempted on the day before your scheduled appointment as a courtesy. If it is necessary to cancel your appointment, please call us as soon as possible. A minimum of 24hrs notice is required for cancelling appointments. If less than 24hr notice is given, the appointment will be considered 'Missed'. If you do not cancel in advance and do not attend the office for your visit, this will be considered a 'No Show' appointment. ***After the first No Show or Missed appointment, a $25.00 a fee will be charged at the Provider's discretion***
I have read the above policy and sign below to indicate that I have understood it's contents.
*
I agree
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