Full Name
*
First Name
Middle Name
Last Name
Sex
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Email
*
example@example.com
Race
*
American Indian/Native American
Asian
Black
Pacific Islander/Native Hawaiian
White
I prefer not to answer
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Emergency Contact
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone #
*
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Pharmacy Name
*
Pharmacy Phone #
*
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Insurance or Self Pay
*
Insurance
Self-Pay
Insurance Name
Insurance Policy Number
Insurance Policy Group Number
Payment Guarantor:
Me
Not Me
Guarantor Name
*
First Name
Middle Name
Last Name
Guarantor's Relationship to Patient
*
Guarantor's Phone Number
*
Please enter a valid phone number.
Guarantor's Date of Birth
*
-
Month
-
Day
Year
Date
Guarantor's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Financial Responsibility Approval
*
By signing above, I acknowledge full financial responsibility for any financial responsibility for any services rendered and I understand that the payment of charges incurred in this office is due at the time of service. I also understand that the charges not covered by insurance remain my responsibility and assign insurance benefit to the office. If my account is turned over to collection agency, I agree to pay all fare fees (2% compounded monthly), costs of collection fee (up to $250) and attorney's fees and all court costs, if any.
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Please read the A&U Family Medicine Notice of Privacy Practices
Date
*
-
Month
-
Day
Year
Date
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HIPAA Release: Please list anyone you would like to have access to your Protected Health Information/Records
*
If you are 18 years or older, we will not disclose any information with anyone not listed above.
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How would you like to upload your ID and Insurance?
*
Upload picture/file
Take picture with phone camera
Give upon arrival
Please upload front and back side of your ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Photo of your ID
Please upload the front and back of your Insurance ID card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Photo of your Insurance ID
Please give your ID and/or Insurance to office staff upon arrival
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New Patient Health Questionnaire
Medications (including dosages and frequency)
*
Please email your medications list with the dosages and frequencies to eesha.khan@aufamilymedicine.com. If you are not taking any medications, please send an email saying that you are not taking any medications. Thank you!
Please list any medications (prescription, over the counter, vitamins, etc.) you are currently taking
Allergies
*
Please list any allergies
Past Medical History
High Blood Pressure
High Cholesterol
Diabetes
Cancer
Heart Attack
Heart Failure
Chest Pain
Asthma
Pneumonia
Tuberculosis
Seasonal Allergies
Weight Gain/Loss
Hemorrhoids
Gallbladder Disease
Liver Disease
Thyroid Disease
Headaches
Seizures
Stroke
Fractures/Broken bones
Arthritis
Gout
Blood clots
Anemia
Skin Disease
Kidney Disease
Kidney Stones
Anxiety
Depression
Hearing Problems
Vision Problems
Other
Operations/Hospitalizations
*
Family History
*
Please list any family medical history for Parents, Grandparents, children, siblings, etc.
Diet
*
What do you typically eat on a day-to-day basis?
Do you exercise? If yes, how much.
*
Do you smoke or have you have smoked?
*
Yes
No
Quit Smoking
Do you drink alcohol?
*
Yes
No
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Submit
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