Name
Date of Birth
SS#
Primary Phone #
Alternate Phone #
Address
City
State
Zip Code
Allergies to medication/ food
List of current medications
In case of emergency, we must have a phone number other than ‘your’ cell or alternate, we need a neighbor, relative, or friend number:
Name
Phone
Relationship
Next of Kin Name
Address
Phone
Relationship
Assignment of insurance benefits/ Consent to treatment:
I authorize payment of insurance benefits otherwise payable to me directly to the doctor. I also consent to treatment by the health care providers of the medical practice. I also herby authorize the release of my information concerning my health care, advice, and treatment provided for the purpose of evaluation and administrating claims for insurance benefits. I understand that if I were to be seen for a motor vehicle accident (MVA) I will be held liable to pay $125 regardless of insurance coverage or contacts held by the doctor and my insurance company. I acknowledge that I have received a copy of the Privacy Notice and was given an opportunity to object to disclosures of my protected health information.
Patient Signature (please type full legal name)
Date
Social History
Tobacco use
How many years?
Have you quit smoking or attempted to quit?
Alcohol consumption
Family health history
Past Medical History
Major Events (surgeries, major illnesses, history of cancer, etc)
Ongoing medical problems (including high blood pressure, high cholesterol, prior diagnosis of diabetes, etc)
Nutrition history (please describe your regular diet, and how many meals you eat per day)
Preventive Care (indicate if you are on any type of treatment such as dialysis, weight loss medication or therapy, counseling, etc)
Preferred Pharmacy
Name
Phone #
Address
Submit
