New Patient Registration Form
Please scroll down and complete the fields below.
Patient First Name
Patient Middle Name
Patient Last Name
Patient Ethnicity:
Hispanic/Latino
Not Hispanic/Latino
Patient Race
Patient Language
Patient Bday Month
Patient Bday Day
Patient Bday Year
Patient Age
Patient Sex
Male
Female
Patient Home Phone (area code)
Patient Home Phone (prefix)
The first three digits of your phone number.
Patient Home Phone (line number)
The last four digits of your phone number.
Patient Cell Phone (area code)
Patient Cell Phone (prefix)
The first three digits of your cell phone number.
Patient Cell Phone (line number)
The last four digits of your cell phone number.
Patient email
example@example.com
Patient Street Address
Patient City
Patient State
Patient ZIP Code
Patient's Employer
Patient Employer (area code)
Patient Employer (prefix)
The first three digits of the phone number.
Patient Employer (line number)
The last four digits of the phone number.
Marital Status - Single
Single
Married
Divorced
Widowed
Referred by (please check one)
Family
Friend
Newspaper
Yellow Pages
Insurance Company
Search Engine (Google, Bing)
Doctor*
Hospital*
Other*
*Referring Doctor's Name
If you selected Doctor above, please specify a name.
*Referring Hospital's Name
If you selected Hospital above, please specify a name.
*Referring Source: Other
If you selected Other above, please specify.
Pharmacy (Name & Location)
Do you have an advance directive?
Yes
No
Family Doctor (PCP)
Insurance Information
Primary Insurance
Subscriber's Name
Subscriber SSN (first three digits)
Subscriber SSN (second two digits)
Subscriber SSN (last four digits)
Subscriber Bday Month
Subscriber Bday Day
Subscriber Bday Year
Insurance Group No.
Insurance Policy No.
Patient Relationship to Subscriber
Self
Spouse
Child
Other
Secondary Insurance (if applicable)
Secondary Insurance Subscriber's Name
Secondary Insurance Subscriber's SSN (first three digits)
Secondary Insurance Subscriber's SSN (second two digits)
Secondary Insurance Subscriber's SSN (last four digits)
Secondary Insurance Subscriber's Birthdate
Secondary Insurance Subscriber's Group No.
Secondary Insurance Subscriber's Policy No.
Secondary Insurance Patient Relationship to Subscriber
Self
Spouse
Child
Other
IN CASE OF EMERGENCY
Name of friend or relative
Emergency Contact - Relation to Patient
Emergency Contact Home Phone (area code)
Emergency Contact Home Phone (prefix)
The first three digits of the phone number.
Emergency Contact Home Phone (line number)
Last four digits of the phone number.
Emergency Contact Mobile Phone (area code)
Emergency Contact Mobile Phone (prefix)
The first three digits of the mobile phone number.
Emergency Contact Mobile Phone (line number)
Last four digits of the mobile phone number.
Pediatric Patients
Legal Gaurdian Name
Legal Gaurdian - Relation to Patient
Signature
Patient I Guardian signature
Signature Date Month
Signature Date Day
Signature Date Year
Back
Next
PATIENT RESPONSIBILITY
Please read all of the following and acknowledge by signing below.
SIGNATURE OF PATIENT, PARENT OR GUARDIAN
Relationship to Patient
Patient Responsibility Signature Date (month)
Patient Responsibility Signature Date (day)
Patient Responsibility Signature Date (year)
What office location would you like this form sent to?
*
Belle Haven
Churchland
Corporate Landing
Franklin
Norfolk
Suffolk
Virginia Beach Town Center
Back
Next
Date of Birth
-
Month
-
Day
Year
Date
Date Last Updated
-
Month
-
Day
Year
Date
Name of Medication -1
Strength and Frequency
Condition Medication Taken For
Physician who Prescribed Med
Notes
Name of Medication - 2
Strength and Frequency
Condition Medication Taken For
Physician Who Prescribed Med
Notes
Name of Medication - 3
Strength and Frequency
Condition Medication Taken For
Physician Who Prescribed Med
Notes
Name of Medication - 4
Strength and Frequency
Condition Medication Taken For
Physician who Prescribed Med
Notes
Name of Medication - 5
Strength and Frequency
Condition Medication Taken For
Physician who Prescribed Med
Notes
Name of Medication - 6
Strength and Frequency
Condition Medication Taken For
Physician who Prescribed Med
Notes
Back
Next
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
Date
1. Need to blow nose
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
2. Nasal Blockage
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
3. Sneezing
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
4. Runny nose
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
5. Cough
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
6. Post-nasal discharge
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
7. Thick nasal discharge
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
8. Ear fullness
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
9. Dizziness
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
10. Ear pain
No problem
Very mild decision
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
11. Facial pain/pressure
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
12. Decreased sense of smell/taste
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
13. Difficulty falling asleep
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
14. Wake up at night
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
15. Lack of a good night's sleep
No problem
Very mild problem
Mild or slight prevention
Moderate problem
Severe problem
Problem as bad as it can be
16. Wake up tired
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
17. Fatigue
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
18. Reduced productivity
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
19. Reduced concentration
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
20. Frustrated/restless/irritable
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
21. Sad
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
22. Embarrassed
No problem
Very mild problem
Mild or slight problem
Moderate problem
Severe problem
Problem as bad as it can be
Most important 5 items
Need to blow nose
Nasal blockage
Sneezing
Runny nose
Cough
Postnasal discharge
Tick nasal discharge
Ear fullness
Dizziness
Ear pain
Facial pain/pressure
Decreased sense of smell/taste
Difficulty falling asleep
Wake up at night
Lack of a good night's sleep
Wake up tired
Fatigue
Reduced productivity
Reduced concentration
Frustrated/restless/irritable
Sad
Embarrassed
Other
Back
Next
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
This information may be released to:
Spouse
Child(ren)
Other
Please do not release information to anyone other than my primary care physician and/or referring physician.
Spouse Name
First Name
Last Name
Child(ren)'s Name(s)
First Name
Last Name
Other Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Preview PDF
Submit
Back
Next
Should be Empty: