COVID-19 Patient Registration

Registration Form
Patient Information
Patient's last name: *
First: *
Middle:
Is this your legal name?

Yes No
If not, what is your legal name?
Mr. Mrs. Miss Ms.
Marital Status

Single Married Divorced Separated Widowed
(Former name):
Date of birth *

Month Day Year
Date
Age:
Sex: *

M F
Phone no.: *
Street address: *
P.O. Box:
City: *
State: *
ZIP Code: *
Occupation:
Employer:
Employer phone no.:
Insurance Information
Subscriber's name:
Name of Primary Insurance: *
Birth date:

Month Day Year
Date
Relationship to Insured

Self Spouse Child Other
Name of secondary insurance (if applicable):
Policy Number:
Group number:
In Case of Emergency
Name:
Relationship to patient:
Home phone no.:
Work phone no.:
ASSIGNMENT AND RELEASE:

·         I hereby assign my insurance benefits to be paid directly to the physician

·         I understand that I am financially responsible for all non-covered services, copays, deductibles and/or coinsurance. I authorize and give consent for my provider to bill me directly for recommended services performed that are not covered or not exempted under the terms of my health plan.

·         I authorize the physician to release any medical information required to process this claim.
CONSENT TO TREAT

·         I authorize my provider’s office to conduct telehealth visits when necessary.

·         I authorize New Path Medical Center to identify and carry out the appropriate treatment and/or procedure for any identified condition(s).

·         I understand I have the right to refuse any procedure or treatment

·         I understand I have the right to discuss all medical treatments with my clinician.

·         I authorize New Path Medical Center to perform any laboratory testing deemed clinically necessary.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize New Path Medical Center or insurance company to release any information required to process my claims.
Patient/Guardian signature *

Clear
Date *

Month Day Year
Date
Review of Systems
Do you currently have any of the following symptoms? (Check all that apply)

Weakness Fatigue Nasal discharge Nasal infections Cough Short of breath Coughing Runny nose Abdominal pain Vomiting Diarrhea Nausea
COUNTY OF RESIDENCE:
NUMBER OF DAYS WITH SYMPTOMS:
Any recent travel?

Yes No
IF YES, WHERE:
Have you been in contact with someone that tested positive for COVID-19?

Yes No
Medical History
Today's Date:

Month Day Year
Date
Name:
DOB:
Chief Complaint: What is the reason for your visit today( please describe problem in detail)
Past Medical History: Please check all that apply to you

Arthritis Psychiatric disease Cancer Heart problems Stroke Depression Epilepsy/seizures Heart surgery High blood pressure Thyroid Diabetes None Other
Previous Surgeries:
Current Medications and Dosage
Preferred Pharmacy
City
Allergies: please list any allergies you have:
Do you smoke?

Yes No
If yes, how many cigarettes/day?
Do you drink alcohol?

Yes No
If yes, how much/week?
Do you consume caffeine?

Yes No
If yes, how many cups or cans/week?
Do you use recreational drugs?

Yes No
If yes, what type and frequency?
Are you on a special diet?

Yes No
If yes, please describe:
Number of sexual partners in the last 12 months:
Do you have sex with:

Males Females Both
Females Only
Number of pregnancies:
Date of last menstrual period:

Month Day Year
Date
Number of Miscarriages:
Number of Abortions:
Date of menopause:

Month Day Year
Date
Please upload a photo of a valid Photo ID
Please upload a photo of your insurance card
Should be Empty:

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Registration Form

Patient Information

Insurance Information

In Case of Emergency

Review of Systems

Medical History

Females Only