New Patient Form You may use the form on this page to generate a "New Patient Information Form" which will be sent to our office. You'll also be able to conveniently download a copy for yourself. If you prefer, click here to download the blank form (PDF) and fill it out manually. Registration Form * 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: Relationship: Additional Person 2: Relationship: Patient Signature: Signature of Parent Guardian:
