New Patient Registration

New Patient Registration Form
Patient Name *
Date of Birth *

/ Month / Day Year
Date
Reason for Visit *
Requested Physician
Social Security Number
Gender *

Female Male
Marital Status

Single Divorced Widowed Separated Married Engaged

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Race
Ethnicity
Preferred Language

English Spanish
Upload a copy of your driver's license or other photo ID. *

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Contact Preferences
Cell Phone

- Area Code Phone Number
Work Phone

- Area Code Phone Number
Home Phone

- Area Code Phone Number
Preferred Phone
May we leave detailed voicemails for you?

Yes No
Email
example@example.com

Emergency Contact
Emergency Contact *
Relationship to Pt
Phone Number *

- Area Code Phone Number
May we speak to your emergency contact about your healthcare? *

Yes No
Please list the names of anyone else we may speak with about your healthcare. *
Family, Friends, Caregivers, etc

Insurance
Do you have active health insurance? *

Yes No
Primary Insurance
Primary ID #
Secondary Insurance
Secondary ID #
Upload photos of your insurance card(s) - front and back.

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Guarantor
Guarantor Name *
Name of subscriber on insurance/Financially responsible party
Date of Birth

/ Month / Day Year
Date
Relationship to Pt

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone

- Area Code Phone Number

Policy Agreement
Please check all of the boxes to indicate your acknowledgement of these important points from our policies. *

I have reviewed the information above for correctness and have made any and all changes necessary. I hereby authorize and consent to exams, treatments, and release of medical information to insurance, claim representatives, adjusters, and other physicians necessary to process claims and assign to the physician payment for services. A copy of the Notice of Privacy Practices has been made available to me on the website and in the office. I may ask questions about this notice at any time. I understand that I must bring my insurance card to every visit. All copays, deductible, and coinsurances are due at the time of service. I must put a credit card on file or pay an estimate at each visit. If I refuse, I will need to reschedule. I am responsible for checking my email for billing information. It is my responsibility to know my benefits and preferred providers (for labs and services) I must arrive 15 minutes prior to my appointment time. I must notify the office at least 24 hours prior to my appointment if I am unable to make it.
Signature *

Signature Clear

Health History
Allergies *
Please list the allergen and your reaction to it.
List any hospitalizations and/or surgeries. *
List dates and reasons for each.
Current Medication List (REQUIRED: You must include dosages,frequency and reason.) *
REQUIRED: List dosage, frequency, and reason for each medication.
Local Pharmacy *
Name, Location, and Phone Number Required
Mail Order Pharmacy
Name, Location, and Phone Number Required
Current Medical Problems *

Anxiety Depression Diabetes Heart Problems High Blood Pressure High Cholesterol Lung Problems Thyroid Problems None

Other Health Care Providers
Previous Primary Care Doctor *
Name and Location
Cardiologist
Name and Location
Dermatologist
Name and Location
Endocrinologist
Name and Location
Gynecologist
Name and Location
Oncologist
Name and Location
Ophthalmologist
Name and Location
Urologist
Name and Location
Any other providers? *
Name and Location

Health Maintenance
For each of the following services, please provide a date, location, provider, and a result to the best of your knowledge.
Colonoscopy
Date, Location, Provider, and Result
Pap Smear
Date, Location, Provider, and Result
Mammogram
Date, Location, Provider, and Result
PSA (Prostate Check)
Date, Location, Provider, and Result
DEXA (Bone Density Test)
Date, Location, Provider, and Result
Eye Exam *
Date, Location, Provider, and Result
Pneumonia Shot
Date, Pneumovax or Prevnar?
Flu Shot *
Date
Shingles Shot
Date, Zostavax or Shingrix?
Tetanus Shot
Date

Family History
Family History *

Breast Cancer Colon Cancer Prostate Cancer Diabetes Heart Attack Heart Problems Stroke High Blood Pressure High Cholesterol Osteoporosis Anxiety or Depression Psychological, Drug, or Alcohol Problems None
Who in your family was/is affected by breast cancer?
Who in your family was/is affected by high cholesterol?
Who in your family was/is affected by diabetes?
Who in your family was/is affected by a heart attack?
Who in your family was/is affected by heart problems?
Who in your family was/is affected by a stroke?
Who in your family was/is affected by colon cancer?
Who in your family was/is affected by prostate cancer?
Who in your family was/is affected by osteoporosis?
Who in your family was/is affected by anxiety/depression?
Who in your family was/is affected by psychological, drug, or alcohol problems?
Who in your family was/is affected by high blood pressure?

Social History
Tobacco/Nicotine Use Status *
How much and how often do you use tobacco (or nicotine)?
1 pack per day
Interested in quitting?

Yes No
How much and how often do you drink alcohol? *
Tell us about your exercise routine (type and frequency). *
Who lives with you in your home?
Do you have children? What are their names and ages?
Occupation *
Employer
Employment Status

Full-Time Part-Time Retired Unemployed
What are your hobbies?
How did you hear about our practice?
Do we currently see any of your family members?
Should be Empty: