New Patient Information

In order for us to obtain a complete medical history and treat the medical condition that you are seeking help with; we need this form filled out as completely as possible.

Patient Full Name: This field is required.

Birth Date

This field is required.

Gender of Patient

Gender

Male
Female
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This field is required.

Address This field is required.

Home Phone Number This field is required.

Cell Number This field is required.

Social Security No. This field is required.

Email Address This field is required.

Online medical access

Yes or No

Yes
No
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This field is required.

Primary Care Doctor This field is required.

Preferred Pharmacy This field is required.

Reason for Today’s Visit This field is required.

Authorization of Release of Information

I authorize the following person/people to discuss any necessary appointments, treatments, medications, test results, or anything else related to my medical care and/or appointment scheduling. I authorize the following person/people to bring in my child in for treatment and to discuss any appointments, treatments, medications, test results or anything else related to their medical care and/or appointment scheduling.

Full Name This field is required.

Relationship to Patient This field is required.

Phone Number This field is required.

Who would you like us to contact in the case of an emergency?

Full Name This field is required.

Relationship to Patient This field is required.

Phone Number This field is required.

List All Medications and Supplements You Are Taking (Or provide us with a list of your own) This field is required.

Allergies to Medications:

Yes or No

Yes
No
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This field is required.

Allergies to Medications: If yes, please list below This field is required.

Have you or any family member ever had an unusual reaction to anesthesia?

Yes or No

Yes
No
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This field is required.

If yes,Who: This field is required.

MEDICAL HISTORY

Past Medical History

(Please check appropriate boxes)

Heart Attack
Asthma
Diabetes
Emphysema
Coronary Artery Disease
Thyroid
Cancer
Bleeding Disorder
Kidney Disorder
Stroke
Hepatitis
Glaucoma
Hypertension
Heart Failure
Arthritis
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This field is required.

for Diabetes, (Insulin Yes/No)

(Insulin Yes/No)

Yes
No
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This field is required.

for Thyroid, what type: This field is required.

for Cancer, what type: This field is required.

Other: This field is required.

Past Surgical History (Enter approximate date for procedure that applies)

Ear Tubes: This field is required.

Septoplasty: This field is required.

Tonsillectomy This field is required.

Sinus Surgery: This field is required.

Hernia: This field is required.

Heart Bypass: This field is required.

Cataracts: This field is required.

Back/Neck: This field is required.

Appendix: This field is required.

Gall Bladder: This field is required.

Other: This field is required.

Family History (Please write who among your immediate family has the following)

Strokes: This field is required.

Diabetes: This field is required.

Heart Disease: This field is required.

Breast Cancer: This field is required.

Thyroid disorders: This field is required.

Allergies: This field is required.

Asthma: This field is required.

Hypertension: This field is required.

Hearing Loss: This field is required.

Cancer: This field is required.

Other: This field is required.

Patient Signature:

Clear

Date Signed:

This field is required.