New Patient Form

Legal Name {Required} *

First

Middle

Last

Preferred Name

Gender

Female
Male

Other

Other

Other Info

Date Of Birth {Required} *

Current Age *

Address {Required} *

Address Line 1

City

State

Zip Code

Please Contact By:

Home Phone
Cell Phone
Email

Is it okay to leave a message if we call you? *

Home #

Cell #

Emergency Contact

Relationship

Phone Number

Pharmacy:

Address Line 1

City

State

Zip Code

Previous Provider:

MEDICAL HISTORY

Conditions

Other

MEDICATIONS

Medication Name

Dose

Frequency

Medication Name

Dose

Frequency

Medication Name

Dose

Frequency

Medication Name

Dose

Frequency

ALLERGIES

Drug Allergy

Reaction

Non-Drug Allergy

Reaction

Drug Allergy

Reaction

Non-Drug Allergy

Reaction

Drug Allergy

Reaction

Non-Drug Allergy

Reaction

SURGICAL HISTORY

Procedure

Approximate Date:

Procedure

Approximate Date:

Procedure

Approximate Date:

Procedure

Approximate Date:

TESTS (List Approximate Dates)

Mammogram:

Prostate Exam:

PAP Smear:

Stress Test:

Shingles:

Bone Density:

Hearing Test:

Tenanus:

Colonoscopy:

Foot Exam:

FLU:

Eye Exam:

EKG:

COVID-19:

Other Test:

Approximate Date:

LIST ALL OTHER DOCTORS/SPECIALISTS/PROVIDERS WHO PARTICIPATE IN YOUR CARE

Primary Care

Cardiologist

Dermatologist

Endocrinologist/Hormone

Gastroenterologist

Pulmonologist/lung

Nephrologist/Kidney

Neurologist/Nervous Sys

OB/GYN Womens Health

Oncologist/Hematologist Cancer

Orthopedic Doctor Bone/Muscle

Otolaryngologist Ear/Nose/Throat

Pain Management

Physical Therapy

Psychiatrist or Counselor

Rheumatologist

Social/Case Worker

Urologist Kidney/Bladder

Other

SOCIAL HISTORY

Tobacco
Smokeless
Quit Smoking

Packs/Uses Per Day:

Smoking?

Quit Smoking?

Alcohol

Drinks Per Week

Treatment

Quit Drinking?

Drugs

Type?

Treatment

Quit?

Medical Marijuana

Reason:

How Long?

Exercise

Type?

Minutes Per Day

Days Per Week

Employer

Fulltime
Part Time
Retired
Disabled

Insurance

Attach a photo of the front and back of your insurance card or complete all of the fields below

Attach Picture of Insurance Card (Front)

Click or drag a file to this area to upload.

PNG;JPG;JPEG;BMP - 5MB Limit

Attach Picture of Insurance Card (Back)

Click or drag a file to this area to upload.

PNG;JPG;JPEG;BMP - 5MB Limit

Subscriber Name

Date Of Birth

Insurance Name

Effective Date

Cert Number

Group Name

Group Number

Policy Telephone Number

Secondary Insurance

Attach a photo of the front and back of your 2nd insurance card or complete all of the fields below

Attach Picture of 2nd Insurance Card (Front)

Click or drag a file to this area to upload.

PNG;JPG;JPEG;BMP - 5MB Limit

Attach Picture of 2nd Insurance Card (Back)

Click or drag a file to this area to upload.

PNG;JPG;JPEG;BMP - 5MB Limit

Subscriber Name

Date Of Birth

Secondary Insurance Name

Effective Date

Cert Number

Group Name

Group Number

Policy Telephone Number

Tertiary Insurance

Attach a photo of the front and back of your 3rd insurance card or complete all of the fields below

Attach Picture of 3rd Insurance Card (Front)

Click or drag a file to this area to upload.

PNG;JPG;JPEG;BMP - 5MB Limit

Attach Picture of 3rd Insurance Card (Back)

Click or drag a file to this area to upload.

PNG;JPG;JPEG;BMP - 5MB Limit

Subscriber Name

Date Of Birth

Tertiary Insurance Name

Effective Date

Cert Number

Group Name

Group Number

Policy Telephone Number

Race, Ethnicity, Language, and Disability (REALD)

Do you need written materials in an alternate format (Braille, large print, audio recordings, etc.)?

Yes
No
Don't know/Unknown
Don't want to answer/Decline

If yes, which format?

Race and Ethnicity

Which of the following describes your racial or ethnic identity? Please check ALL that apply

American Indian or Alaska Native

American Indian
Alaska Native
Canadian Inuit, Metis, or First Nation
Indigenous Mexican, Central American, or South American

Black or African American

African American
African (Black)
Caribbean (Black)
Other Black

Hispanic or Latino/a

Hispanic or Latino/a Central American
Hispanic or Latino/a Mexican
Hispanic or Latino/a South American
Other Hispanic or Latino/a

Middle Eastern/Northern African

Northern African
Middle Eastern

White

Eastern European
Slavic
Western European
Other White

Other Categories

Don't know/Unknown
Don't want to answer/Decline

How do you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry?

Enter the one that best represents your racial or ethnic identity if you select more than one above.

Language

In what language do you want us to:

Speak with you

Write to you

Do you need a sign language interpreter for us to communicate with you?

Yes
No
Don't know/Unknown
Don't want to answer/Decline

If yes, which type do you need us to communicate with you? (ASL, PSE, tactile interpreting, etc.)

Do you need an interpreter for us to communicate with you?

Yes
No
Don't know/Unknown
Don't want to answer/Decline

Disability

Your answers to the questions below help us find health and service differences among people with disabilities or limitations. Your answers are confidential.

Are you deaf or do you have serious difficulty hearing?

Yes
No
Don't know/Unknown
Don't want to answer/Decline