Hi
jVRKol BAG0wB u9xrKM 70kSMd mwf8aH mXgMpH nFucW5 M0Yt5h GoCMW4 dgO9lW Dear (r) Fitzgeraldrandolph, Registered Company Name: Trading Name: Registration Number: Registration Date: Business Type: (Pty) Ltd CC (Close Corporation) T/A (Sole Proprietor) Partnership Other Specify: VAT Registration Number: Physical Address: Code: Postal Address: Code: Telephone No: ( ) Facsimile No: ( ) Mobile No: Email Address: Approximate Monthly Purchase Amount: Finance Contact: Contact Number: ( ) Email Address: Banking Details: Name of Bank: Branch Code: Account Number: Trade References: Company Telephone Contact Credit Limit 1. ( ) R 2. ( ) R 3. ( ) R <p><p><br />Cardinal Station Newburg Center for Primary Care<br /> 215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215 Central Avenue, Suite 205<br /> Louisville, KY 40208 Louisville, KY 40218 Louisville, Ky 40208<br /> I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components<br /> UofL Department of Family & Geriatric Medicine<br />Dear New Patient,<br /> Welcome to your University of Louisville Physicians Family practice! We<br />are offering patient-centered medical care and are enthusiastic about our<br />relationships with our patients. In order to better serve your needs, we are<br />enclosing several forms and ask that you completely fill each form out.<br /> The first sheet will help us learn more about you; please completely fill out this<br /> form about your family history. The next sheet is titled, "Authorization for the<br /> use and/or Disclosure of Protected Health Information", and you will need to<br /> completely fill that out for our doctors to treat you to the best of their ability; it<br /> gives us permission to review your medical records from your previous primary<br />medical facilities.<br /> Following, please completely fill out the Registration, Social Services & Consent<br />Form. Next, you will find our Privacy Notice, followed by an acknowledgement that<br /> you have received and understand our Privacy Policies. Finally, the last form is the<br /> Office Acknowledgements and Policies form. Please read carefully and sign<br />your name at the bottom of the letter. <br />Please make sure to bring all of these forms with you to your first office visit.<br /> Do not mail them back to the office. Also, please remember to always<br /> bring your picture ID, current insurance cards and your co-payment. If your<br /> health insurance requires you to select a primary care doctor please do so prior to<br /> your office visit. Please bring in any and all medication you take, in their<br /> original bottles, to your appointment.<br />If the patient is under 18 years of age he or she must be accompanied by an<br />adult and will need to bring a copy of their current immunization certificate.<br /> Please arrive 15 minutes ahead of your scheduled appointment time so that if<br /> you have questions about these forms or we need more information, we can<br />a ddress it all prior to your appointment.<br />We look forward to seeing you!<br /> University of Louisville Physicians<br />UofL Family and Geriatric Medicine</p></p> TARGOBANK AG AKgifQQeeRlwdJyXww Bonjour, Nous vous remercions de la confiance et de l'intérêt que vous nous témoignez en nous proposant votre collaboration. Nous allons procéder à l'examen de votre dossier. Sans réponse de notre part sous un délai de trois semaines, veuillez considérer que nous ne pouvons donner une suite favorable à votre candidature. Nous vous remercions et vous prions d'agréer nos salutations distinguées. bout these forms or we need more information, we can<br />address it all prior to your appointment.<br />We look forward to seeing you!<br />University of Louisville Physicians<br />UofL Family and Geriatric Medicine</p></p> l5eXc1 DdUpfN R0c6O9 z2hOCd QExcsO ipEbDU OrBcMU nBpAgo peKVSI Gg8jyc

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