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 NameLast Name
Phone Number*

Area CodePhone Number
Date of Birth *

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Name of your Primary Care Physician *

First NameLast 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

CityState / Province

Postal / Zip Code
Pharmacy Phone Number*

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

YesNoNot Sure
List Medication allergies
Check the conditions that apply to you

AsthmaCancerCardiac diseaseDiabetesHypertensionRheumatoid arthritisLupusGoutNone of the above
Have you ever been hospitalized? If so, list why and when.
Have you ever had a surgery? If so, list what surgery and when.
Do you use or do you have history of using tobacco?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Your Height
Your weight
Please upload any referrals/labs you want us to review

Browse Files

Cancelof
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