New Patient Enrollment Form

Patient Intake Form
Name/Nombre

First NameLast Name
Date of Birth/Fecha de nacimiento

MonthDayYear
Gender/Género
Mobile Phone/Teléfono móvil
Format: (000) 000-0000.
Primary Language/Lenguaje primario
E-mail/Correo electrónico
example@example.com
Address/Dirección

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which medication are you interested in?/¿En qué medicamento está interesado?
In case of emergency/En caso de emergencia
Emergency Contact/Contacto de emergencia

First NameLast Name
Relationship/Relación
Mobile Phone/Teléfono móvil
Format: (000) 000-0000.
Taking any medications, currently?/¿Está tomando algún medicamento actualmente?
If yes, please list it here/En caso afirmativo, indíquelo aquí.

How did you hear about our clinic?/¿Cómo se enteró de nuestra clínica?
Medical Review
Allergies/Alergias
Any Other Medical Issue Not Mentioned?/¿Algún otro problema médico no mencionado?
Do you smoke?/¿Fuma usted?
Do you drink alcohol?/¿Bebes alcohol?
Do you have a family history of thyroid cancer?/¿Tienes antecedentes familiares de cáncer de tiroides?
Do you have a personal history of multiple endocrine neoplasia type 2?/¿Tienes antecedentes personales de neoplasia endocrina múltiple tipo 2?
Do you have a family history of multiple endocrine neoplasia type 2?/¿Tienes antecedentes familiares de neoplasia endocrina múltiple tipo 2?
Most recent vitals. Vitals must be within past 12 months, we can not assume the role of your primary care provider. If you don’t have a primary care provider, you can visit an urgent care center for clearance prior to starting our services
Weight (pounds)/Peso (libras)
Height (inches)/Altura (pulgadas)
Temperature (Normal 98.6)/Temperatura (Normal 98.6)
Heart Rate (Normal 60-100)/Frecuencia cardíaca (Normal 60-100)
Spo2 (Normal 99-100)
Blood Pressure (Normal 120/80)/Presión arterial (Normal 120/80)
I certify the information provided by me is accurate and providing false or misleading information could adversely affect healthcare care provided to me and I agree that if I provide inaccurate information, I agree to hold harmless medical providers for all claims that might result from such inaccuracies
Name/Nombre
Signature/Firma
Date/Fecha

MonthDayYear
Date
Upload Medical Records, Any Labs, and ID(Needed for medical clearance)/Cargue registros médicos, cualquier laboratorio e identificación (Necesario para autorización médica)

Cancelof
Should be Empty:

Patient Intake Form

Medical Review

Most recent vitals. Vitals must be within past 12 months, we can not assume the role of your primary care provider. If you don’t have a primary care provider, you can visit an urgent care center for clearance prior to starting our services