New Patient Registration

New Patient Registration
Please fill out as completely as possible. All patient information is confidential. * Indicates a required response.

Patient Information
* Patient First Name: M.I.
* Patient Last Name:
* Address 1:
Address 2:
* City: * State:
* Zip: Province:
* Country:
* Home Tel: Bus. Tel: Ext.
Status: Married Divorced Separated Widow Single Other
* Age:
Today's Date (MM/DD/YY) Please add slashes:
* Date of Birth (MM/DD/YY) Please add slashes: * Social Security #:
* Sex: male female
Referring Physician:
Work Status: Retired Unemployed Employed Full Time Part Time/Full Time Student
Employer: Employer Tel:

Primary Insurance Information
Primary Insurance Company Name:
Primary Insurance Company Patient ID#:
Primary Insurance Company Group ID#:
Primary Insurance Holder First Name: M.I.
Primary Insurance Holder Last Name:
Date of Birth (MM/DD/YY) Please add slashes: Age:
Social Security #:
E-Mail:
Relationship: Self Spouse Father Mother Other

Secondary Insurance Information
Secondary Insurance Company Name:
Secondary Insurance Company Patient ID#:
Secondary Insurance Company Group ID#:
Seconday Insurance Holder First Name: M.I.
Seconday Insurance Holder Last Name:
Date of Birth (MM/DD/YY) Please add slashes: Age:
Social Security #:
E-Mail:
Relationship: Self Spouse Father Mother Other

Medical History/Review of Symptons
Please give us an overview of your medical history by completing the following:

Have you had or do you have any of the following medical conditions? (check all that apply)

high blood pressure
emphysema (or lung problems)
cirrhosis of the liver
osteoporosis
thyroid problems
lupus
irregular heart beat
asthma
pneumonia
kidney problems
arthritis
anxiety
myocardial infarction
(or heart desease)
cancer, site

esophageal reflux
hepatitis a, b, c
diabetes, type I or II
rheumatic fever
high cholestrol
sickle cell anemia
epilepsy
positive HIV test
keloids
migraine headaches
anemia
cataracts
stomach or duodenal ulcer
(or GI problems)
other

coronary artery disease
tuberculosis
colitis
hiatal hernia
AIDS
enlarged prostate
skin cancer
depression
infectious mononucleosis
blood disorder
lyme disease
glaucoma
bladder problems
(or gynecologic problems)

Past Medical, Family, Social History

List your current medication including over-the-counter drugs such as aspirin, Tylenol, Motrin, nasal sprays, etc.

1. Medication and Dose:				Reason for Taking:
2. Medication and Dose:				Reason for Taking:
3. Medication and Dose:				Reason for Taking:

Please list your Drug Allergies

1. Drug Allergy:				Type of Reaction:
2. Drug Allergy:				Type of Reaction:
3. Drug Allergy:				Type of Reaction:

Family History

skin cancer

skin disease

bleeding disorder

Social History
Tobacco
Do you currently smoke? yes no
Number of years you smoked?
Number of packs per day?

Alcohol
Do you drink alcohol? yes no
How much do you drink? daily weekly

Occupation:
Are you now pregnant? yes no
Are you currenly breast feeding? yes no
Do you require premedication with antibiotics before a dental or surgical procedure? yes no

Emergency Contact Information

* Name:
* Home Phone:
Work Phone:
Mobile Phone:

Please check with your insurance company if you need a referral to see us. If your health insurance plan requires a referral to see us, and you don't have one at the time of your appointment, we have to bill you at the time of your appointment or reschedule your appointment. Please bring the referral with you to your appointment or have it electronically sent to us by your doctor. If your doctor has questions, please have him/her call us at (856) 424-9230.

Thank you and we look forward to seeing you.