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  • Welcome!

  • Welcome to Christine Meyer, MD and Associates! We are honored that you have chosen to partner with us for your health.

    As a new patient, we invite you to tell us about you! This new-patient questionnaire will allow us to build a comprehensive medical chart for you, so we start off strong. We know it is a lot of questions, but take your time and tell us your health story. We're listening. 

    This questionnaire will take about 20 minutes. It is a HIPAA-secure form. You cannot pause and come back later to finish, so take a few minutes to gather any documentation you may need for the details, including:

    • Medical insurance cards, if you have insurance
    • Preferred local pharmacy name and Location
    • Mail-away pharmacy name and Location
    • Emergency contact name, phone, and address
    • Medical conditions you have
    • Chronic conditions you have
    • Other healthcare providers or specialists you see (name and most recent visit)
    • Dates of your last: physical exam, colonoscopy, and blood work
    • Dates of your last: flu shot, Pneumovax, Prevnar, Tetanus, Shingles vaccine, and any other vaccines
    • Surgeries, hospitalizations and ER visits
    • Medications you currently take
    • Allergies
    • Family history (immediate family members who have relevant conditions)
    • Females: Date of last period, Pap smear, gyn exam, mammogram
    • Males: Date of last PSA screening and prostate exam

    Click below to get started, and contact us if you have any questions.

  • Tell us about you.

  • Emergency Contact

  • Insurance Information

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  • Your Medical History

  • For the following vaccines and appointments, enter a date if known. If you do not know, enter "Unknown". If you have never had it, write "None."

  • For the following questions, enter a date if known. If you do not know, enter "Unknown". If you have never had it, write "None."

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  • Tobacco and Alcohol:

  • I currently use   *   *   times per   *   .

  • I consume approximately *   alcoholic drinks per   *   .

  • I use   *   approximately *   times per   *   .

  • Social History

    Our practice does not discriminate on the basis of sexual orientation, gender identity, or expression. In order to effectively treat our patients, please consider answering the following questions:

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  • Consents & Releases

  • Authorization for Verbal Communication and Release Of Health Information

    I authorize the physicians and staff at Christine Meyer MD & Associates to leave detailed messages and/or speak with persons other than myself regarding information specific to my medical care, including test results, on the phone number(s) listed below. I understand that once a voicemail message exists it is no longer covered under HIPAA and therefore is not protected from unauthorized access. I understand that this authorization can be revoked at any time by submitting a written request to the practice. Information will not be left with an unauthorized person who may answer the telephone. Please note: we will not leave messages on an answering machine that does not have the name or telephone number on the recorded message.
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  • Consent for Release and Use of Confidential Information and Receipt of Notice of Privacy Practices Form

  • I, *   *, as the Patient or Authorized Legal Representative, hereby give my consent to the practice to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of       , Date of Birth:   Pick a Date   .

    I acknowledge receipt of the practice’s Notice of Privacy Practices. The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information. I understand that the practice has reserved a right to change its privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me and/or available to me on the christinemeyermd.com website. 

    I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so, to the practice. I also understand that I will not be able to revoke this consent in cases where the practice has already relied on it to use or disclose my health information. Written revocation of consent must be sent to the practice’s office.

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  • Receipt of Notice of Privacy Practices Form:

  • I, *   *, as the Patient or Authorized Legal Representative, hereby acknowledge receipt of the Notice of Privacy Practices.   Pick a Date   

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  • Thank you for taking the time to complete this form.

    Before you click Submit, scroll up and be sure that all required fields (marked with a red asterisk*) are completed. You will be unable to submit the form without all of the required fields.

    We are honored to welcome you to our practice and to partner in your care! We look forward to seeing you at your first appointment.

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