PATIENT REGISTRATION FORM - share. quo. com Holding one’s mouth open can, in a predisposed patient, precipitate a TMJ disorder Gums and surrounding tissues may also be sensitive or painful during and or after treatment
REFERRAL: 5 4 2026 PATIENT INFORMATION SOC: 05 08 2026 PATIENT INFORMATION NAMEMata, Tony (805) 444-7586 Santa Paula, CA 93060 401 King Ct 000013179-001 Hussein, Aisha (4719) ADDRESS CITY STATE ZIP PHONE NUMBER MEDICAL RECORD STATUS D C REASON CASE MANAGER PATIENT NO : 13179 SEX: Male DATE PLAN ESTABLISHED: 05 07 2026 SSN:
Once on the Patient Portal, click on the ‘Log In’ button Once on the Patient Portal, click on the ‘Log In’ button Enter in the email you provided to the THH representative you spoke with on the phone Enter the password you chose when you first signed up for the Portal (when you clicked on the link in the ‘Client Portal Invitation’ email)
$o w, - share. quo. com Patient Acupuncture Massage Patient Narne: 5"^,Y^ Priraary [ns: Co-pay: $ visit Ins pay: $_
1 of 1 - share. quo. com True Sports Physical Therapy 2810 East Prospect Road York, PA 17402 (717) 699-8680 (443) 842-5766 Patient: Valerie Bailey DOB: Feb 15, 1977
Samaritan Home Health Care, Inc. Patient Profile SPECIAL INSTRUCTIONS Primary Language: Primary: LA Care Health Plan 99980595G Secondary: Medicaid 99980595G CLINICIANS INSURANCE INFORMATION PHARMACY INFORMATION ADMITTING DIAGNOSIS INITIAL ORDERS (Include Reason for Admission Evaluation) Admitting Physician: CHAI, JASON J Address: 517 S ORANGE AVE APT A MONTEREY PARK, CA 91755 Phone: (626) 377-8148 Fax #: ( ) - NPI: 1124805924 Patient Contact Person Name: Address: Relationship: Home Phone: Mobile Phone: Email Address: SOLARES NANCY CA SISTER (323) 817-5767 Category: Interpreter: Age: 47 Allergies: No Known Allergies Staff Signature: __________________________ Date: ________
share. quo. com Quest Diagnostics Incorpor ated Patient Information BAL-KNIGHT: BAYLOR 137 STEEPLECHASE RD BELTON: SC 29627 864-376-5456 Pat ID 118302703 SSN: DOB: 8 12 2002 Sex: M Result Noffication: Normal 10608758-10737264 Account No: 10608758 Ivydale Wellness Center 367 resource Parkway Winder: GA 30680 770-291 0419 Collection Date: 05 06 2026 For Lab Use