New Patient Registration

1
Geolocation
2
Patient's Name* This field is required.
First Name
Middle Name
Last Name
3
Patient's Date of Birth* This field is required.
Date of Birth
Month
Day
Year
4
Patient's Sex* This field is required.
Male
Female
5
Patient's Cell Phone Number* This field is required.
6
Patient's Alternative Phone Number (Optional)
7
Do you wish to received reminder texts and phone calls about your appointments?* This field is required.
YESNO
8
Patient's Email* This field is required.
Email
Confirm Email
9
Patient's Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Upload Photo IDPlease upload a copy of your photo ID, such as a driver's license or passport.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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11
Marital Status* This field is required.
Single
Married
Partner
Divorced
Separated
Windowed
Minor
12
Primary Language Spoken* This field is required.
English
Chinese (Mandarin)
Chinese (Cantonese)
Chinese (Other)
Vietnamese
Spanish
Korean
Japanese
Armenian
French
Farsi
Cambodian
Tagalog
Hindi
Urdu
Telugu
Punjabi
Tamil
13
Ethnicity* This field is required.
Non-Hispanic
Hispanic/Latino
Decline to State
14
Race* This field is required.
White
African American
Asian
Hawaiian/Other Pacific Islander
Native Amerian
Decline to State
15
Employment Status
Working
Unemployed
Leave of Absent
Going to school
Retired
16
OccupationWhat is your current or most recent occupation?
17
EmployerPlease list your current or most recent employer.
18
Emergency Contact's Name* This field is required.
First Name
Middle Name
Last Name
19
Relationship of Emergency Contact* This field is required.
Spouse
Partner
Significant Other
Friend
Child
Sibling
Cousin
Grandparent
Uncle/Aunt
20
Emergency Contact's Phone Number* This field is required.
21
Preferred Pharmacy* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
Primary Insurance Type* This field is required.
PPO
POS
EPO
HMO/IPA
Medicare
TRICARE/VA
Cash/Self-Pay
23
Primary Insurance Plan (PPO/POS/EPO)* This field is required.Please select your primary health insurance policy's carrier.
Blue Shield of California
Anthem Blue Cross
United Healthcare
Cigna
Aetna
Health Net
Blue Cross/Blue Shield Federal Employee Program
Blue Cross/Blue Shield (Out of State Plans)
Oscar
24
Primary Insurance Plan (HMO/IPA)* This field is required.Please select your IPA or medical group.
Associated Hispanic Physicians (AHP)
Advanced Medical Doctor of CA (AMDC)
Caremore
Exceptional Care Medical Group (Conifer)
Health Care LA IPA
Optum/Healthcare Partners
Stewart Medical Group
Southland San Gabriel Valley
Southland Advantage
Regal (Medicare and Commercial)
Serendib Healthways
Global Care Medical Group
Imperial Health Plan
LA Care Direct Network
25
Primary Insurance Member ID #* This field is required.For Medicare patients: please enter your 11-digit New Medicare ID #. For TRICARE patients: use the "Benefits Number" listed on the back of your ID card.
26
Upload FRONT of Primary Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
27
Upload BACK of Primary Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
Do you have a secondary insurance policy?* This field is required.
YESNO
29
Secondary Insurance Type* This field is required.
PPO
POS
EPO
HMO/IPA
Medicare
TRICARE/VA
Medi-Cal
30
Secondary Insurance Plan (PPO/POS/EPO)* This field is required.Please select your primary health insurance policy's carrier.
Blue Shield of California
Anthem Blue Cross
United Healthcare
Cigna
Aetna
Health Net
Blue Cross/Blue Shield Federal Employee Program
Blue Cross/Blue Shield (Out of State Plans)
31
Secondary Insurance Plan (HMO/IPA)* This field is required.Please select your IPA or medical group.
Advanced Medical Doctor of CA (AMDC)
Associated Hispanic Physicians (AHP)
Caremore
Exceptional Care Medical Group
Health Care LA IPA
Optum/Healthcare Partners
Southland San Gabriel Valley Medical Group
Southland Advantage
Stewart Medical Group
Serendib Healthways
Regal (Medicare and Commercial)
LA Care Direct Network
Imperial Health Plan
32
Secondary Insurance Member ID #* This field is required.For Medicare patients: please enter your 11-digit New Medicare ID #. For TRICARE patients: use the "Benefits Number" listed on the back of your ID card.
33
Medi-Cal Issue Date (Secondary Insurance)* This field is required.Please enter the Issue Date listed on your Medi-Cal card.
Month
Day
Year
34
Upload FRONT of Secondary Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
35
Upload BACK of Secondary Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
36
Is someone else financially responsible for your medical bills (guarantor)?* This field is required.*Required for minors less 18 years-old
YESNO
37
Guarantor's Name* This field is required.
First Name
Middle Name
Last Name
38
Relationship of Guarantor* This field is required.
Spouse
Partner
Significant Other
Friend
Child
Sibling
Cousin
Grandparent
Uncle/Aunt
39
Guarantor's Date of Birth* This field is required.
Month
Day
Year
40
Guarantor's Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
41
Guarantor's Phone Number* This field is required.
42
Guarantor's Email* This field is required.
example@example.com
Confirm Email
43
Were you referred by another doctor or healthcare provider?* This field is required.
YESNO
44
Referring Provider's Name* This field is required.
Dr.
Dr.
NP
PA
Other
Prefix
First Name
Last Name
45
Referring Provider's Address
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
46
Is the referring provider also your primary care provider (PCP)?* This field is required.
YESNO
47
Do you have a primary care provider (PCP)?* This field is required.
YESNO
48
PCP's Name* This field is required.
Dr.
Dr.
NP
PA
Other
Prefix
First Name
Last Name
49
PCP's Address
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
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Guinea
Guinea-Bissau
Guyana
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
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Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
50
What is the reason for your visit?* This field is required.
51
Have you had a colonoscopy before?* This field is required.
YESNO
52
How recent was your last colonoscopy?* This field is required.
Don't remember
less than 1 year ago
1-2 years ago
3-4 years ago
5 years ago
6-9 years ago
10 years ago
>10 years ago
53
Name of the doctor who perform your last colonoscopy
Dr.
Dr.
NP
PA
Other
Prefix
First Name
Last Name
54
Result of Last Colonoscopy* This field is required.If known, please specify that type of colon polyps that were found on your previous colonoscopies.
Normal
Don't remember
Polyp(s)
Poor Preparation
Hemorrhoid
Diverticulosis
55
Do you have a history of colon polyps?* This field is required.
YESNO
56
Types of Colon Polyps* This field is required.If known, please specify that type of colon polyps that were found on your previous colonoscopies.
Don't Know
Hyperplastic Polyps
Adenomas
Sessile Serrated Adenomas
Inflammatory Polyps
57
Do you have a personal history of colon cancer?* This field is required.
YESNO
58
Do you have a family history of colon cancer?* This field is required.
YESNO
59
Family Members with Colon Cancer* This field is required.Please list any known family members with colon cancer. Click "SAVE" after each new entry.
60
Family Medical HistoryFor each close relative, please select any of the corresponding diagnoses. If you're on a mobile device, use the arrows to toggle between each condition.
Father
Mother
Brother
Sister
Other
Deceased
Ucerative Colitis
Colon Cancer
Colon Polyps
Diabetes
Crohn's Disease
Gastrointestinal Cancer
Mental Disorder
Celiac Disease
Deceased
Ucerative Colitis
Colon Cancer
Colon Polyps
Diabetes
Crohn's Disease
Gastrointestinal Cancer
Mental Disorder
Celiac Disease
Father
Mother
Brother
Sister
Other
Father
Mother
Brother
Sister
Other
Father
Mother
Brother
Sister
Other
Father
Mother
Brother
Sister
Other
Father
Mother
Brother
Sister
Other
Father
Mother
Brother
Sister
Other
Father
Mother
Brother
Sister
Other
Father
Mother
Brother
Sister
Other
Father
Mother
Brother
Sister
Other
1 of 9
61
Past GI Medical History - Esophagus* This field is required.Do you have any of the following GI-related medical problems of the esophagus?
None
Heartburn/GERD/Acid Reflux
Barrett's Esophagus
Reflux Esophagitis
Eosinophilic Esophagitis
Esophageal Stricture or Narrowing
Achalasia
Esophageal Spasm
Esophageal Cancer
Zenker's Diverticulum
62
Past GI Medical History - Stomach* This field is required.Do you have any of the following GI-related medical problems of the stomach?
None
H. Pylori Infection
Stomach Cancer
Gastric Ulcer
Gastrointestinal Bleeding
Gastroparesis
Gastritis
63
Past GI Medical History - Small/Large Intestine* This field is required.Do you have any of the following GI-related medical problems of the small or large intestine?
None
Crohn's Disease
Ulcerative Colitis
Irritable Bowel Syndrome (IBS)
Colon Polyps
Colon Cancer
Diverticulosis
Diverticulitis
Chronic Constipation
Chronic Diarrhea
Duodenal Ulcer
Celiac Disease
Microscopic Colitis
64
Past GI Medical History - Anorectal* This field is required.Do you have any of the following GI-related medical problems of the anus or rectum?
None
Hemorrhoid
Anal Fissure
Anal Fistula
Perianal Abscess
Anal Cancer
Anal Wart
65
Past GI Medical History - Liver* This field is required.Do you have any of the following GI-related medical problems of the liver?
None
Abnormal Liver Tests
Hepatitis B
Hepatitis C
Liver Cirrhosis
Liver Cancer
Liver Transplant
Alcoholic Liver Disease
Fatty Liver Disease/NASH
66
Past GI Medical History - Pancreas/Gallbladder* This field is required.Do you have any of the following GI-related medical problems of the pancreas or gallbladder?
None
Acute Pancreatitis
Chronic Pancreatitis
Pancreatic Cancer
Gallstones
Cholecystitis
Gallbladder Cancer
Cholangiocarcinoma
67
Other Past Medical History* This field is required.Do you have any of the following non-GI medical problems?
None
Diabetes
High Blood Pressure
High Cholesterol
Coronary Artery Disease
Heart Attack
Heart Failure
Heart Valve Problem or Murmur
Atrial Fibrillation/Atrial Flutter
Abnormal Heart Rhythm
Peripheral Vascular/Arterial Disease
Blood Clots in Vein (DVT or PE)
COPD
Sleep Apnea
Asthma
Chronic Kidney Disease
End-stage renal disease (Dialysis)
Non-GI Cancer
Anemia
Bleeding Disorder
Morbid Obesity (BMI >40)
Endometriosis
Seizure Disorder
HIV
Stroke/TIA
Thyroid Disorder
Drug/Chemical Dependent
Anxiety
Depression
Active or Latent TB
68
Past Surgical/Procedure History* This field is required.Have you have any of the following surgeries or procedures done?
None
Gastric bypass/Weight loss surgery
Colon Resection
Cholecystectomy (Gallbladder)
CABG (Coronary Artery Bypass)
Heart Valve Surgery
Coronary Stents Placement
Pacemaker/Defibrillator Placement
Peripheral Vascular Bypass
Hysterectomy
Kidney Transplant
Liver Transplant
Whipple's
Small Bowel Resection
Ileostomy or Colostomy
Hemorrhoid Surgery or Banding
Hernia Repair
69
Are you currently taking any medications?* This field is required.
YESNO
70
Do you consent for our office to obtain your medication history from your pharmacy?* This field is required.If you consent, you may skip listing your medications at the next page. This will provide us with the most accurate medication list.
YESNO
71
Please list all active medicationPlease include all over-the-counter medications and supplements, and herbal supplements in addition to your prescription medication. If you're on a mobile device, use the arrows at the bottom to enter the next medication.
Name of Medication
Dose
Frequency
Interval
1
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
2
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
3
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
4
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
5
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
6
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
7
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
8
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
9
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
10
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
11
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
12
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
13
Once
Twice
Three Times
Four Times
Five Times
As needed
Daily
Weekly
Bi-Weekly
Monthly
14
Once
Twice
Three Times
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Five Times
As needed
Daily
Weekly
Bi-Weekly
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15
Once
Twice
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As needed
Daily
Weekly
Bi-Weekly
Monthly
1
2
3
4
5
6
7
8
9
10
11
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14
15
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
Name of Medication
Dose
Frequency
Once
Twice
Three Times
Four Times
Five Times
Interval
As needed
Daily
Weekly
Bi-Weekly
Monthly
1 of 15
72
Do you have any drug or non-drug ALLERGIES?* This field is required.
YESNO
73
Allergies* This field is required.Please list all allergies and their reactions. Click "SAVE" after each new entry.
74
How much alcohol do you drink weekly?* This field is required.
None
1-2 Drinks/Week
3-5 Drinks/Week
6-10 Drinks/Week
> 10 Drinks/Week
75
How much caffeine do you consume daily?* This field is required.
None
1-3 cups of teas/coffee/soda
≥ 4 cups of tea/coffee/soda
76
Do you smoke?* This field is required.
Never Smoker
Current Smoker - Everyday Smoker
Current Smoker - But not everyday
Former Smoker
77
Do you currently or previously use any recreational drugs?* This field is required.
YESNO
78
Check all recreational drugs that you previously or currently use* This field is required.
Marijuana
Cocaine
Heroine
Narcotics/Opiates
Methamphetamine
79
How often do you exercise per week?* This field is required.
Never
1-2x/week
3-5x/week
Everday
80
Review of Systems: General* This field is required.Do you have any of the following symptoms?
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weigh Loss
81
Review of Systems: Gastrointestinal* This field is required.Do you have any of the following symptoms?
None
Abdominal Pain
Abdominal Bloating
Change in bowel habits
Constipation
Diarrhea
Gas Pain or Excess Gas
Heartburn
Jaundice
Nausea/vomiting
Rectal Bleeding
Stomach Cramps
Difficulty Swallowing
Vomiting Blood
Black, Tarry Stool
Hemorrhoid
82
Review of Systems: Cardiovascular* This field is required.Do you have any of the following symptoms?
None
Chest pain or angina
Irregular heart beat
Palpitations
Edema/ankle swelling
Faint/loss of consciousness
83
Review of Systems: Eyes* This field is required.Do you have any of the following symptoms?
None
Double Vision
Loss of Vision
84
Review of Systems: Ears, Nose, and Throat* This field is required.Do you have any of the following symptoms?
None
Nose Bleed
Sore Throat
85
Review of Systems: Respiratory* This field is required.Do you have any of the following symptoms?
None
Asthma
Cough
Shortness of Breath
Excess Sputum/Phlegm
Coughing up Blood
86
Review of Systems: Hematologic/Lymphatic* This field is required.Do you have any of the following symptoms?
None
Easy bruising
Prolonged Bleeding
Enlarged Lymph Nodes
87
Review of Systems: Endocrine* This field is required.Do you have any of the following symptoms?
None
Excess Thirts
88
Review of Systems: Integumentry* This field is required.Do you have any of the following symptoms?
None
Itching
Rashes
89
Review of Systems: Allergic/Immunologic* This field is required.Do you have any of the following symptoms?
None
Strong Allergic Reaction
90
Review of Systems: Musculoskeletal* This field is required.Do you have any of the following symptoms?
None
Arthritis
Back Pain
Joint Pain
Muscle Weakness
91
Review of Systems: Neurological* This field is required.Do you have any of the following symptoms?
None
Dizziness
Fainting
Frequent Headaches
Migraine
Numbness/Tingling
Tremor
Vertigo
Memory Loss
Fall
92
Review of Systems: Psychiatric* This field is required.Do you have any of the following symptoms?
None
Anxiety
Depression
Difficulty sleeping
Panic Attacks
Currently seeing a therapist
93
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94
Do you consent to any family members or friends to give or receive your medical information?* This field is required.
YESNO
95
Consent to Disclose Patient Health Information to Family and FriendsThe individual(s) named below is/are directly involved in my care and I would like these individuals to give and receive information from my physician orGenesis Healthcare/Unio Health Partners regarding my medical condition and treatment.
Friend/Family Full Name #1
Spouse/Partner
Parent
Child
Sibling
Other Relative
Friend
Relationship of Friend/Family Full Name #1
Friend/Family Full Name #2
Spouse/Partner
Parent
Child
Sibling
Other Relative
Friend
Relationship of Friend/Family Full Name #2
96
Notice of Privacy Practices* This field is required.
97
Cancellation Policy & Procedure Billing Information* This field is required.
98
Consent for Treatment & Financial Authorization* This field is required.
99
Financial Policy* This field is required.
100
Medical Records Release & Communication Consent* This field is required.
101
Signature* This field is required.By signing below, I certify that the above information is correct to the best of my knowledge.
Clear
102
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