New Patient Form

Registration Form

Please complete all required fields.

* Date:

* Referred By:

* Full Name:

* Gender:

* Cell Phone:

* Email Address:

* Address:

* City:

* State:

* Zip Code:

* Date of Birth:

Age:

Work Phone:

Home Phone:

Employer:

Name of Spouse:

Employer:

Work Phone:

Please complete this section if Patient is a minor.

Father’s Name:

Birth Date:

Employer:

Work Phone:

Mother’s Name:

Birth Date:

Employer:

Work Phone:

Insurance

Primary Insurance:

Secondary insurance:

Health History Questionnaire

Current Medications:

Are you allergic or have you reacted adversely to any of the following medications? (If yes, please check):
* Latex: NoYes

Are you allergic to any of the following? (check all that apply)

Penicillin

Tetracycline

Erythromycin

Other Antibiotic

If yes, what is the other antibiotic:

Aspirin

Codeine

Local Anesthetic

* Any medication allergy: NoYes

List any medication allergies:

Past surgical history

Please check any of the following which you have had or have now.
Heart Failure
Heart Disease or Attack
Anemia
High Blood Pressure
Emphysema
Mitral Valve Prolapse
TB
Congenital Heart Lesions
Artificial Heart Valve
Heart Pacemaker
Heart Surgery
Heart Murmur
Diabetes
Kidney Disease
Ulcers
Arthritis
Cough
Cold Sores
Asthma
Hay Fever
Allergies or Hives
Venereal Disease
Stroke
Blood Transfusion
Bruise Easily
Thyroid Disease
Drug Addiction
Rheumatism
Fever Blisters
Glaucoma
Sinus Problems
Aids HIV
X-ray Radiation or Cobalt
Hepatitis or Liver Disease
Angina Pectoris
Sickle Cell Disease
Scarlet Fever
Hemophilia
Rheumatic Fever
Cortisone Medicine
Epilipsy or Siezures
Fainting or Dizzy Spells
Chemotherapy Cancer or Leukemia

I certify that the above information is true.

Signature:

Date:

Acknowledgement of the Notice of Privacy Practices

Date:

* Patient Name:

Patient DOB:

Please complete this section if Patient is a minor.

Name of Parent or Guardian:

Relationship to Patient:

Please list name of person(s) that you would allow our office to give information to regarding your medical condition.

* Additional Person 1:

Please type “None” if you do not wish to allow anyone to receive information regarding your medical condition.

Relationship:

Additional Person 2:

Relationship:

* Patient Signature:

Signature of Parent Guardian:

Office Address

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New Patient Form

Registration Form

Health History Questionnaire

Acknowledgement of the Notice of Privacy Practices

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