Prospective Patient Registration Form (PRF)

Prospective Patient Registration Form
Full Name*

First NameLast Name
Age*
Email Address*
john@example.com
Phone Number*

Area CodePhone Number
Where do you live?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Who referred you to us?*

Internet searchFacebook groupFriendOther
What's the name of the person that referred you to us?
What's the name of the Facebook group that referred you to us?
What internet search provider did you find us on?
e.g. Google, Yahoo, Bing, Facebook, Instagram, YouTube, etc.

About Your Health
Type of cancer?*
When were you first diagnosed?*
Stage of cancer?*
What has been done for your cancer and what are the results thus far?*

Patient Agreement
I,*

First NameLast Name
give my express permission to Healthy And Strong, Dr. Daniel Thomas DO, MS and Dr. Sylvia Torres-Thomas PhD, APRN, FNP-C, along with their assigns, to contact me and obtain access to my medical records. I understand that my personal, personal health information ("PHI"), and medical information will be stored on a HIPAA-compliant password-protected secure cloud server.
- By supplying my email address above, I understand that I am granting permission for the office of Dr. Daniel Thomas, Inc. to communicate with me by email for such things as laboratory results, appointment reminders, health updates, and responding to medical questions.
- I understand that Dr. Thomas is not a substitute for my primary-care provider and the care that he or she provides. The purpose of Dr. Thomas is to supplement, not replace, the relationship between me and my primary-care physician.
- I understand that a doctor-patient relationship is not established until I am seen in person or through telemedicine appointment by Dr. Thomas and that no medical recommendations can be legally given until such time.
Date of Birth*

MonthDayYear
Signature*

Clear
Today's Date*

MonthDayYear
Please verify that you are human*
Patient acknowledges and agrees that Dr. Daniel Thomas and Dr. Sylvia Torres-Thomas, along with their assigns, will be entitled to use any data, discoveries, results, improvements, or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications. The patient acknowledges receiving a copy of the Notice of Privacy Practices and Informed Consent. All data will be kept on a secured and encrypted Cloud-Based system that is password-protected, and only accessible to Healthy And Strong staff.
Copyright © {todaysDate34:year} Dr. Daniel Thomas, Inc.

Dr. Daniel Thomas, DO, MS | Dr. Sylvia Torres-Thomas, Ph.D., APRN, FNP-C
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Prospective Patient Registration Form

About Your Health

Treatment Contraindications

Patient Agreement