New Patient Registration

New Patient Registration Form
Patient Information
Full Legal Name*

First NameMiddle NameLast Name
Preferred Name*

First NameMiddle NameLast Name
Have you legally changed your name in the last 5 years?*

YesNo
Preferred Pronoun*

He/HimShe/HersThey/ThemOther
Date of Birth*

MonthDayYear
Email Address*
example@example.com
Mailing Address*
Cell Phone*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Employer
Position
Employer Address:
Emergency Contact:*
Phone Number*
Please enter a valid phone number.
Relationship*
Preferred Communication*

PhoneEmailTextOther
Gender Identity*

MaleFemaleTransgender MaleTransgender FemaleNon-BinaryOther
Sex Assigned at Birth*

MaleFemaleOther
Race*

WhiteBlackAsianNative Hawaiian/Pacific IslanderAmerican IndianOther
Ethnicity*

Hispanic/LatinoNon-Hispanic/LatinoDecline to State
Language*

EnglishSpanishAmerican Sign LanguageOther
Primary Care Physician*
Phone #*
Please enter a valid phone number.
City/State*
Referring Physician
Phone #
Please enter a valid phone number.
City/State
Preferred Pharmacy*
Address*
Phone #
Please enter a valid phone number.
Responsible Party. If the patient is under 18 years of age
Name*

First NameMiddle NameLast Name
Social Security Number
Phone #
Please enter a valid phone number.
Full Address
Relationship to Patient*
Procedures of Interest
Transgender Female *

Breast AugmentationBody FeminizationOrchiectomyVaginoplastyPenectomyFacial FeminizationOtherNone
Transgender Male*

Body MasculinizationTop SurgeryTesticular ImplantsPectoral ImplantsFacial MasculinizationCosmetic SurgeryNone
TF Procedures Calc
TM Procedures Calc
Upload Torso Front View (see example above)*

Cancelof
Upload Torso Side View (see example above)*

Cancelof
Upload Pelvis Front View (see example above)*

Cancelof
Upload Pelvis Side View (see example above)*

Cancelof
Upload Face Front View (see example above)*

Cancelof
Upload Face Side View (see example above)*

Cancelof
Primary Medical Insurance: Medicare/Medicaid/Medi-Cal/Commercial
Insurance*
Phone #
Please enter a valid phone number.
Member ID #*
Group #
Policy Holder Name*
Date of Birth*

MonthDayYear
Date
Relationship to Patient

SelfSpouseParentGuardianDomestic Partner
Patient’s name with insurance*
Listed Gender*

MF
Secondary Medical Insurance: Medicare/Medicaid/Medi-Cal/Commercial
Insurance
Phone #
Please enter a valid phone number.
Member ID #
Group #
Policy Holder Name
Date of Birth

MonthDayYear
Date
Relationship to Patient

SelfSpouseParentGuardianDomestic Partner
Patient’s name with insurance
Listed Gender

MF
Medical History
Height*
Weight*

Condition/Disease

	Yes	No
Anemia
Arthritis
Asthma
Bleeding Disorder
Cancer
Clotting Disorders
Migraines
Stroke
Depression
Sleep Apnea
Anxiety
Heart Disease
High Blood Pressure
High Cholesterol
Thyroid Disease
Liver Disease
Renal Disease
Diabetes
Emphysema (COPD)
Bipolar
Suicidal

Other
Family Medical History

Condition/Disease

	Yes	No
Anemia
Arthritis
Asthma
Bleeding Disorder
Cancer
Clotting Disorders
Migraines
Stroke
Depression
Sleep Apnea
Anxiety
Heart Disease
High Blood Pressure
High Cholesterol
Thyroid Disease
Liver Disease
Renal Disease
Diabetes
Emphysema (COPD)
Bipolar
Suicidal

Allergies to medications or other
Surgeries
Social History

Social History

	Yes	No	Frequency
Caffeine
Smoking cigars or cigarettes
Vaping/Other nicotine or tobacco
Smoking Marijuana
Alcohol
Other drugs

Medications
Surgery Requirements
Continuous hormone therapy for at least a year*

YesNo
Established relationship with a mental health provider*

YesNo
How many years?
Currently on hormone treatments*

YesNo
Can you get clinical support letters before your surgery?*

YesNo
Date*

MonthDayYear
Date
Upload insurance card front*

Cancelof
Upload insurance card back*

Cancelof
Upload ID card*

Cancelof
Assignment and Release: I hereby authorize my insurance to pay benefits to Art Surgical. I am financially responsible for non-covered services. I authorize Art Surgical to release any information to my insurance company required to process any claims.
Signature of Patient, Parent, Guardian, or Personal Representative

Clear
Date

MonthDayYear
Date
Printed name of Patient, Parent, Guardian, or Personal Representative
Relationship to Patient
By checking this box, I agree to receive text messages from ART Surgical (e.g. appointment reminders, clinic updates, etc.) at the number provided. Messages will not include marketing or promotional messages. Msg. and data rates may apply.*

Yes
Should be Empty:

New Patient Registration Form

Patient Information

Responsible Party. If the patient is under 18 years of age

Procedures of Interest

Primary Medical Insurance: Medicare/Medicaid/Medi-Cal/Commercial

Secondary Medical Insurance: Medicare/Medicaid/Medi-Cal/Commercial

Medical History

Family Medical History

Allergies to medications or other

Surgeries

Social History

Medications

Surgery Requirements