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?
Preferred Pronoun
Date of Birth

MonthDayYear
Email Address
example@example.com
Mailing Address
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Position
Employer Address:
Emergency Contact:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Preferred Communication
Gender Identity
Sex Assigned at Birth
Race
Ethnicity
Language
Primary Care Physician
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
City/State
Referring Physician
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
City/State
Preferred Pharmacy
Address
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Full Address
Relationship to Patient
Procedures of Interest
Transgender Female
Transgender Male
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.Format: (000) 000-0000.
Member ID #
Group #
Policy Holder Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Patient’s name with insurance
Listed Gender
Secondary Medical Insurance: Medicare/Medicaid/Medi-Cal/Commercial
Insurance
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Member ID #
Group #
Policy Holder Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Patient’s name with insurance
Listed Gender
Medical History
Height
Weight

Condition/Disease

Rows	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
HIV Positive

Other
Family Medical History

Condition/Disease

Rows	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

Rows	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
Established relationship with a mental health provider
How many years?
Currently on hormone treatments
Can you get clinical support letters before your surgery?
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
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.
By checking "Yes", 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. View our privacy policy here: https://www.artsurgical.net/privacy-policy
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