New Patient Pre Registration

NEW PATIENT PRE-REGISTRATION (to be submitted prior to appointment date) secure (Please enter CORRECT info on this form, as this transfers to your Permanent Medical Record With Us)
Appointment Date/Time*
Patient's Height*
Patient's Weight*
Patient's Full Name (as it appears on insurance card)*

First NameMiddle NameLast Name
Date Of Birth*

MonthDayYear
Marital Status*
Sex*
Race*
Ethnicity
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Employer
Occupation
Highest Level of Education You Have Obtained.
In Case of Emergency
Relationship
Home#
Cell #
Referring Physician:
Phone #
Are the complaints you are seeing us for due to:*
PHARMACY INFORMATION:
Pharmacy Name
Pharmacy Street & City
Phone #
ALLERGIC TO THE FOLLOWING MEDICATIONS : IF YOU ARE NOT ALLERGIC TO ANY MEDICATION PLEASE TYPE 'NKA' IN BOX*
Are you allergic to Adhesive Tape
Are you allergic to Latex
Are you allergic to Kidney Dye
INSURANCE INFORMATION: IF NO INSURANCE PLEASE TYPE "SELF PAY" IN FIRST BOX BELOW
Primary Ins. Name, Address, Phone # (PLEASE PROVIDE ADDRESS ON INS CARD)*
Patient ID #
Group #
Insured Name
Date of Birth
Relationship to Patient
Secondary Ins. Name, Address & Phone # (PLEASE PROVIDE ADDRESS ON INS CARD)
Patient ID #
Group #
Insured Name
Date of Birth
Relationship to Patient
Third Ins. Name, Address & Phone # (PLEASE PROVIDE ADDRESS ON INS CARD)
Patient ID #
Group #
Insured Name
Date of Birth
Relationship to Patient
PAST MEDICAL HISTORY: Please mark the conditions you currently have or have had in the past.
AIDSAlcoholismAnemiaArthritisAsthmaBipolarBleeding DisordersBronchitisCancerCataractsChest Pain
Dental InfectionDepressionDiabetesDiverticulitisEmphysemaGlaucomaGoiterGoutHeart DiseaseHepatitisHIV Positive
High CholesterolHigh Blood PressureIncontinence/BladderKidney DiseaseLiver DiseaseMigraine HeadachesMultiple SclerosisObesityOsteoporosisPacemakerPneumonia
Prostate ProblemPsychiatric CareSeizure DisorderSubstance AbuseSleep ApneaStrokeThyroid - HypoThyroid - HyperTuberculosisUlcersOther- please list below
Other Medical History Not Listed Above:
Tobacco Use:

NeverYesPreviously
How long?
Form of tobacco?
How much per day?
When did you stop?
Alcohol Use

NeverOccasional / SocialOther
Have you ever been treated for any type of alcohol or drug abuse dependency?
If yes, please explain:
CURRENT MEDICATION, If YOU ARE NOT ON ANY MEDICATION PLEASE TYPE "N/A" IN FIRST BOX OF MEDICATION, IF YOU HAVE A LIST EITHER COMPLETE THE FOLLOWING OR FAX TO US AT FAX 770-422-4412. WE NEED THIS LIST PRIOR TO YOUR APPT.
Medication*
Reason
Dose
Frequency
Medication
Reason
Dose
Frequency
Medication
Reason
Dose
Frequency
Medication
Reason
Dose
Frequency
Medication
Reason
Dose
Frequency
Additional Medication: One per line as above
PAST SURGERY HISTORY, IF NO PREVIOUS SURGERY PLEASE TYPE "N/A" IN FIRST BOX OF SURGERY PROCEDURE
Surgery Procedure*
Surgery Date
Facility where performed
Surgery Procedure
Surgery Date
Facility where performed
Surgery Procedure
Surgery Date
Facility where performed
Surgery Procedure
Surgery Date
Facility where performed
Surgery Procedure
Surgery Date
Facility where performed
Additional Surgeries: One per line as above
Have you had surgical complications?
If yes, describe:
Have you had the flu vaccination?*
If yes, when? (Estimated Month and Year)
Have you had the pneumonia vaccination?*
If yes, when? (Estimated Month and Year
FAMILY HISTORY (Please list any major medical problems and/or causes of death in your immediate family)
Father
Mother
Siblings
Grandparents
Please check the following box.*

I have read and understand the following paragragh.
1) If you need to reschedule or cancel your appointment, please do so at least 24 hours in advance; failure to notify our office in advance will result in a $50 no-show fee. Early notifications of cancellations allow us to give your time to other patients on our wait list that need to be seen.

2) Please bring any and all diagnostic films & reports (MRI, Ct Scans, EMGs, etc) with you to your scheduled visit. Without the films/CD we are not able to accurately evaluate your condition.
BE SURE AND SUBMIT THIS FORM TO OUR OFFICE BY CLICKING ON THE 'SUBMIT FORM' BUTTON ABOVE:
Thank you.
Should be Empty:

NEW PATIENT PRE-REGISTRATION (to be submitted prior to appointment date) secure (Please enter CORRECT info on this form, as this transfers to your Permanent Medical Record With Us)

PHARMACY INFORMATION:

INSURANCE INFORMATION: IF NO INSURANCE PLEASE TYPE "SELF PAY" IN FIRST BOX BELOW

PAST MEDICAL HISTORY: Please mark the conditions you currently have or have had in the past.

CURRENT MEDICATION, If YOU ARE NOT ON ANY MEDICATION PLEASE TYPE "N/A" IN FIRST BOX OF MEDICATION, IF YOU HAVE A LIST EITHER COMPLETE THE FOLLOWING OR FAX TO US AT FAX 770-422-4412. WE NEED THIS LIST PRIOR TO YOUR APPT.

PAST SURGERY HISTORY, IF NO PREVIOUS SURGERY PLEASE TYPE "N/A" IN FIRST BOX OF SURGERY PROCEDURE

FAMILY HISTORY (Please list any major medical problems and/or causes of death in your immediate family)

BE SURE AND SUBMIT THIS FORM TO OUR OFFICE BY CLICKING ON THE 'SUBMIT FORM' BUTTON ABOVE:

Thank you.