Patient Demographic Information
Last Name
First Name
Middle Name
Maiden Name
Other Names Known By
Date of Birth
Postal Code
P.O. Box #
Island
Street Address
District
Cell (Mobile #)
Home Telephone #
Work Telephone #
Email Address
Driver's License / Passport #
Emergency Contact Name
Relationship To You
Emergency Contact Phone #
Alternative Contact #
ALLERGIES? – Please list any
Insurance Information
Name of patient on card
Name of insured on card
Is the patient the same person as the insured?
If NO what is the relationship of the patient to the insured person?
Insurance Provider
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No Cayman Insurance
Pan-American
Generali
Fidelity
CINICO
CayMed
Cayman First
British Caymanian
BAF
Aetna
Group Name
Policy ID or Number
Member ID #
Plan Name or Type
Effective Date
Other Information
Financial Guarantor in the event that your account is not paid in full by your insurance provider or there is an unpaid balance for any reason.
Name of Responsible Person
Phone
Email
Mailing Address
Consent to treat
I the undersigned, for myself or a minor child or another person for whom I have authority to sign, hereby voluntarily consent to any and all health care treatment and diagnostic procedures provided by Seven Mile Medical Clinic Ltd. (SMMC) and its associated physicians, clinicians and other personnel as deemed reasonable and necessary. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Doctors Care. I understand this consent will continue until cancelled by me in writing.
Initials
Telemedicine
I understand that telemedicine (defined as the use of medical information exchanged from one site to another via electronic communications for the health of the patient, including consultative, diagnostic, and treatment services) may be employed to facilitate my medical care. All electronic transmission of data will be restricted to authorized recipients.
I understand that Cayman law and Cayman courts shall have exclusive jurisdiction in any legal matters arising.
Initials
Consent to Release Medical Information to Insurance Provider
I consent to the use and disclosure of my/the patient's protected health information to my health insurance provider for the purpose of obtaining payment for services rendered to me/the patient and if required to ensure continuity of care e.g. authorization of procedures.
Initials
Deductibles and co-payments will be collected on the day of service. I understand that additional payment may be due once the claim has been settled by my insurance provider and I agree to pay the balance due after settlement with my insurance provider.
Initials
Communication and Use of Data Consent
Your privacy is important to us. Please see our Privacy Notice, which is available from our website at www.sevenmileclinic.ky or on request for more information. In order to communicate with you by text, email or WhatsApp you need to give consent. I consent to SMMC contacting me by text message, WhatsApp or email for the purposes of Clinic newsletters and updates, appointment reminders, test results and other correspondence.
Initials
I understand that text, messages, WhatsApp and email may not be a secure method of communication and there is a risk that they may be read by an unintended party,I also consent to SMMC leaving voicemail messages on the contact telephone numbers provided by me on this form.
Initials
I understand SMMC will be able to use my personal data for legitimate interests in connection with the provision of health care services including but not limited to ordering diagnostic tests and procedures and making referrals to other healthcare professionals. Additional legitimate interests also include compliance with a legal obligation which SMMC is subject to
Initials
Additionally, I authorize the release of my medical information to the individuals named below: (Please initial beside each name)
Name
Relationship
Initials
Name
Relationship
Initials
Name
Relationship
Initials
Appointment Reminders
I acknowledge that appointment reminders may not be sent on all occasions but that the responsibility for attending appointments or cancelling them still rests with me. I understand there may be a fee if I miss an appointment or cancel with less than 24 hours notice.
I Authorize
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I Authorize
I Do Not Authorize
For Minors & Legal Guardians
I am the parent / legal guardian of the patient named on this form. On their behalf I consent to the Release of Medical Information to an Insurance Provider as described above and I agree to be financially responsible for the payment of services they receive. I consent to communication and use of data as described above.
I Agree
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I Agree
I Do Not Agree
For Minors & Legal Guardians
I am the parent / legal guardian of the patient named above. On their behalf I consent to treatment as in the Consent to Treat section above. I consent to the Release of Medical Information as described above and I agree to be financially responsible for the payment of services provided to the patient and to receive information by email and the patient portal.
Patients Name
Parent or Guardian Name Signature
MM/DD/YYYY
Parent or Guardian Name
Parent or Guardian Name Signature
MM/DD/YYYY
Send
