Dallas Rheumatology New Patient Form

New Patient Intake Form

Dear Patient, Please fill out this questionnaire to the best of your ability. This will ensure a much faster appointment with us since we can enter this information into your chart before you come, get your medical records from your referring physicians well in advance of your visit and we can verify that your insurance is active. The safety and security of your information is very important to us and we use the highest levels of security measures in the industry to ensure that we are HIPAA compliant - including SSL and data encryption and PGP protocols. We look forward to taking care of you. At Dallas Rheumatology, we don't just care for you, we care about you.
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Email
example@example.com
Name of your Primary Care Physician

First Name Last Name
Who referred you to us ?
Reason for your visit with us
Primary Insurance Name, Member ID and Group ID
Secondary Insurance name, your member ID and group ID
Name of insured (if not you) and their date of birth
Your pharmacy name
Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pharmacy Phone Number

Area Code Phone Number
Names of medications you are on, their dose and how often you take them
Do you have any medication allergies?

Yes No Not Sure
List Medication allergies
Check the conditions that apply to you

Asthma Cancer Cardiac disease Diabetes Hypertension Rheumatoid arthritis Lupus Gout None of the above
Have you been hospitalized in the last year ? For what ?
Any Surgeries in the last 5 years ? For what conditions ?
Do you use or do you have history of using tobacco?
How often do you consume alcohol?

Daily Weekly Monthly Occasionally Never
Your Height
Your weight
Please upload any referrals/labs you want us to review

Browse Files

Cancel of
By checking this box, I acknowledge that I have had an opportunity to read the practice privacy and financial policy as well as the electronics communication policy. I intend to keep my scheduled appointment. If I am unable to keep my appointment, I will call the practice before my appointment time and reschedule/cancel my appointment. My failure to do so may result in me being charged a $50 no show fee.*
*

I AGREE
Should be Empty:

New Patient Intake Form