• DATE OF BIRTH:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • SEX ASSIGNED AT BIRTH:*
  • CHOOSE WHICH PHONE NUMBER(S) YOU'D LIKE TO PROVIDE (AT LEAST ONE NUMBER IS REQUIRED):*

  • I UNDERSTAND THAT BY PROVIDING MY EMAIL ADDRESS, I CONSENT TO RECEIVING OCCASIONAL EMAILS FROM THE PRACTICE.

  • INSURANCE INFORMATION

  • WHO IS THE PERSON RESPONSIBLE FOR BILLS?*
  • DATE OF BIRTH FOR PERSON RESPONSIBLE FOR BILL*
     - -
    2 digit month, 2 digit day, 4 digit year
  • IS THE PATIENT COVERED BY INSURANCE?*
  • WHAT IS THE PRIMARY INSURANCE?*
  • SUBSCRIBER'S DATE OF BIRTH:
     - -
    2 digit month, 2 digit day, 4 digit year
  • WHAT IS THE PATIENT'S RELATIONSHIP TO THE SUBSCRIBER?*
  • DO YOU HAVE SECONDARY INSURANCE?*
  • WHAT IS THE PATIENT'S RELATIONSHIP TO THE SUBSCRIBER?*

  • EMERGENCY CONTACT INFORMATION

  • PREVENTATIVE MEDICAL HISTORY

    INDICATE MOST RECENT DATES FOR

  • PNEUMOCOCCAL VACCINE

  • MEDICAL HISTORY

    IN EACH DROPDOWN SECTION, CHECK ALL THAT APPLY (CLICK A HEADING TO SHOW THE QUESTION)

  • CARDIAC

  • WHICH CARDIAC CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • RESPIRATORY

  • WHAT RESPIRATORY CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • DIGESTIVE

  • WHAT DIGESTIVE CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • URINARY

  • WHAT URINARY CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • ENDOCRINE

  • WHAT ENDOCRINE CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • HEMATOLOGIC

  • WHAT HEMATOLOGIC CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • NEUROLOGIC

  • WHAT NEUROLOGIC CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • VISION

  • WHAT VISION CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • PSYCHIATRIC

  • WHAT PSYCHIATRIC CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • MUSCULAR

  • WHAT MUSCULAR CONDITIONS DO YOU HAVE A HISTORY OF? (IF NONE APPLY, CHOOSE "NONE")*

  • ADDITIONAL MEDICAL HISTORY

    PLEASE ANSWER THE FOLLOWING
  • ARE YOU ALLERGIC TO ANYTHING?*
  • ARE YOU CURRENTLY TAKING ANY MEDICATIONS?*
  • HAVE YOU HAD ANY SURGERIES?*
  • DO YOU SMOKE TOBACCO*
  • DO YOU DRINK ALCOHOL?*
  • IS YOUR MOTHER LIVING OR DECEASED?*
  • IS YOUR FATHER LIVING OR DECEASED?*

  • LEGAL NOTICES AND ACKNOWLEDGMENTS

  • FINANCIAL POLICY & NOTICE OF PRIVACY PRACTICES (CLICK TO READ)

  • DATE:
     / /
    2 digit month, 2 digit day, 4 digit year
  • DO YOU AUTHORIZE OUR PRACTICE AND ITS REPRESENTATIVES TO DISCLOSE YOUR HEALTHCARE INFORMATION TO OTHERS?*
  • ARE THERE ANY LIMITATIONS TO THE INFORMATION WE MAY DISCLOSE TO THE OTHER PERSON(S) YOU IDENTIFIED?*
  • TODAY'S DATE*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: