VERITAS New Patient Form

NEW PATIENT FORM

Please complete and submit prior to scheduling your first visit. Reminder: Veritas does not refill prescriptions for chronic opiates.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Best Phone Number*
Please enter a valid phone number.
EMERGENCY CONTACT INFORMATION*
RELEASE OF INFORMATION
Health Insurance Information (For ordering tests, referrals, etc)
Former Primary Care Provider
CURRENT MEDICATIONS AND DOSES *
Do you have any of the following chronic conditions?*

DiabetesHeart DiseaseHypertensionCancerNeurologic issuesGI IssuesMemory ProblemsUrologic IssuesGYN IssuesSkin ProblemsENT IssuesOther Endocrine IssuesOrthopedic/Spine ProblemsPulmonary IssuesMental Health IssuesOtherNone
Please describe past medical history*
Any major hospitalizations?*
Any surgeries?*
Dates of prior screening tests
Do you follow with any specialists? Who and why?*
Family Medical Issues
What do you do or have you done for employment? How far did you go in school?
Who do you live with? Do you have a significant other or children?
Smoking: Never, Current or Former? How long?
Marijuana? Vaping?
Any illicit drug use history?
How many alcohol drinks do you have in a week?
How many falls have you suffered in the last year?
Do you feel safe at home and relatively secure with food/finances/housing?
Do you have a priority for your health this year?
Anything else we should know about you?
Should be Empty:

NEW PATIENT FORM