New Patients Medical Registration
All patients are required to fill out a Medical Registration form. Please read each section carefully. You may not need to fill in every section depending on your answers. This should take approximately 15-20 minutes to complete. This form is designed for children under the age of 18.
Parent/Guardian of Patient
*
First Name
Last Name
Relationship to Patient
Patient Name
*
First Name
Middle Name
Last Name
Suffix
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Patient Sex
*
Male
Female
Transgender
Patient Social Security Number (no dashes, PLEASE GIVE FULL 9 DIGIT NUMBER)
*
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Number
*
Best e-mail to reach you
*
example@example.com
Do you consent to receiving messages from our office at the email address listed above?
*
Yes
No
Vaccinations
Our office policy is we do not accept patients that do not vaccinate. We will need Immunization/Vaccination records present before first appointment. We will not be able to schedule the first visit without having those records on file.
Has the Patient received their immunizations/vaccinations?
Yes
No
If "No" Do you plan to have patient vaccinated? (If you answered NO to both of these questions we can not accept you as a patient)
Yes
No
Back
Next
Save
Emergency Contact Information
Emergency Contact
*
First Name
Last Name
Relationship to patient
Phone number of Emergency Contact
*
-
Area Code
Phone Number
Back
Next
Save
Some more personal information we need
Is the patient of Hispanic/Latino decent?
*
Yes
No
Race
Who is the patients current primary care provider? If they don't have one, just put "N/A"
Back
Next
Save
Insurance Information
** PLEASE PROVIDE US WITH COMPLETE INSURANCE INFORMATION. IF WE DO NOT OBTAIN ALL INSURANCE INFORMATION WE WILL BE UNABLE TO SCHEDULE YOU FOR AN APPOINTMENT AT OUR PRACTICE. **
Will you be using insurance, or will you be paying out-of-pocket?
*
Insurance
Out of Pocket
Primary Insurance Name
Primary Insurance Member ID: (IF YOU HAVE INSURANCE PLEASE PROVIDE THE ID NUMBER!!)
Group ID:
Address where insurance claims are to be sent (located on the back of the card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Policy Holder
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Secondary Insurance Name (if none, leave and all the rest blank)
Secondary Insurance Member ID:
Group ID:
Address for secondary where insurance claims are to be sent (located on the back of the card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Policy Holder (if different than primary)
First Name
Last Name
Date of Birth of Secondary Insurance Policy Holder (if different than primary)
-
Month
-
Day
Year
Date
Back
Next
Save
Pharmacy and Medications
Please select the best option...
*
I have a pharmacy that I use.
I don't have a pharmacy.
I might be changing my pharmacy.
Pharmacy Name
Pharmacy Location and Phone Number
Preferred Lab
Lab Location
Preferred Imaging Facility
Imaging Facility Location
If the patient is on any current Medication please list them here along with the dosage. This also includes supplements and Vitamins. If they are not currently on anything put N/A
*
If none put N/A
Does the patient have any allergies to medications? If so, list the medication and the type of reaction they have. If they do not have any allergies put N/A
*
If none put N/A
Back
Next
Save
Pediatric Social & Surgical History
Does the patient have an advance directive?
*
Yes
No
Does the patient smoke?
*
Yes
No
If the answer is "YES", how many cigarettes does the patient smoke per day?
Does the patient use E-cigarettes or Vape?
*
Yes
No
If "YES" how often does the patient use E-cigarettes or Vape?
Is the patient sexually active?
*
Yes
No
Has the patient had an HPV vaccine?
Yes
No
Not Sure
Does the patient have an STI or Sexual Transmitted Disease?
Yes
No
Not Sure
Please list ANY past surgeries, and the approximate date. If the patient doesn't have any past surgeries to report, please write "N/A" below.
*
Home Situation
*
Both parents
Mother
Father
Relatives
Adoptive parents
Foster parents
Other
Does the patient have any siblings?
*
Yes
No
If "YES" please give the number of siblings
Do you have any animals at home?
*
Yes
No
Is the patient ever exposed to cigarette smoke?
*
Yes
No
Do you have working smoke detectors in the home?
*
Yes
No
How about carbon monoxide detectors?
*
Yes
No
I'm not sure.
Are any guns present in the home?
*
Yes
No
Does your family ever have difficulty making ends meet?
*
Yes
No
Have you had any significant changes in your family situation?
*
Yes
No
Do you have concerns about meeting basic needs (food, clothing, housing, school supplies, heat, etc.)?
*
Yes
No
Back
Next
Save
Almost Done! Just a few more things to cover for your child...
What grade is your child in if he has started school?
*
The name of my child's school is...
*
Does your child have an IEP (individualized education plan)?
*
Yes
No
If your child does have an IEP, please select one or more of the following services your child receives in school...
speech-language pathology
occupational therapy
physical therapy
reading specialist
special education
Are you concerned about your child's speech, language, reading, or social development?
*
Yes
No
Are you concerned about bullying?
*
Yes
No
Is your child involved in any extracurricular activities?
*
Yes
No
About how many minutes/hours does your child spend on a smartphone, tablet, or computer?
*
0-1 hours
1-3 hours
Over 3 hours
Please use this area to describe any other concerns that you have regarding your child's medical health, mental health, social development, behavior, literacy, speech/language, or fine/gross motor skills.
*
If you do not have any concerns put N/A
Back
Next
Save
Medical History
These condition are concerning the patient ONLY! Please put family medical history in its respected area!
CONDITIONS
ADD/ADHD
AIDS/HIV
Abuse/domestic violence
Allergies/hay fever
Anemia
Anxiety Disorder
Arthritis
Asthma
Autism spectrum disorder
CONDITIONS Continued...
Birth defects or inherited disease
Bladder or kidney problems
Blood diseases
History of blood transfusion
Breast cancer
Breast problem
COPD
Other type of cancer
Chicken Pox
CONDITIONS Continued...
Chronic ear infections
Congestive heart failure
Constipation outside of typical
Coronary artery disease
Depression
Developmental or behavioral disorders
Diabetes
Difficulty swallowing
Diverticulitis
CONDITIONS Continued...
Ear or hearing problems
Eating disorders
Eczema
Endometriosis
Fibromyalgia
GI problems (stomach)
Gout
Head injury or concussion
Frequent headaches
Heart problems
CONDITIONS Continued...YOU'RE ALMOST DONE!
Hepatitis
High cholesterol
Hypertension
Hypothyroidism
Infertility
Kidney disease
Kidney stones
Liver disease
Mental disorder
Muscle, joint, or bone problems
CONDITIONS Continued...The last batch
Obesity
Osteoporosis
Ovarian cancer
Polyps
Pulmonary embolism
Reflux/GERD
Seizures or epilepsy
Skin problems
Stroke
Turberculosis
Varicosites
Vision or eye problems
Please list any medical history of immediate blood relatives of the patient (Mother, Father, Material & Paternal Grandparents, Brother, Sister)
*
If none then put N/A
Back
Next
Save
One Last Thing
We are always trying to improve the patient experience. Please rate your experience.
Overall, how was your experience filling out this form compared to other online forms?
*
1
2
3
4
5
6
7
Worst
Best
1 is Worst, 7 is Best
Save
Submit
Should be Empty: