New Patient Registration Form
Patient's Legal Name:
First Name
Middle Name
Last Name
Patient’s Social Security Number:
Patient's Birthdate:
-
Month
-
Day
Year
Date
Patient's Marital Status:
Patient's Sex:
Patient's Race:
Patient's Preferred Language:
Patient's Religion:
Patient's Pharmacy:
Patient's Address/P.O. Box
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number/Cell Number:
Please enter a valid phone number.
Patient's Email Address:
Patient's Primary Care Physician:
If patient is under 18 years of age, please list parent or guardian’s information below:
Parent/Guardian's Legal Name:
First Name
Middle Name
Last Name
Parent/Guardian's Social Security Number:
Parent/Guardian's Birthdate:
-
Month
-
Day
Year
Date
Employer's Name:
Employment Status:
Full Time
Part Time
Employer's Phone Number:
Please enter a valid phone number.
Employer's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this visit related to a work related injury/motor vehicle accident:
Yes
No
*if yes, date of injury
-
Month
-
Day
Year
Date
Primary Insurance:
Group No.:
Policy No.:
Subscriber's Name:
First Name
Last Name
Subscriber's Social Security Number:
Subscriber's Birthdate:
-
Month
-
Day
Year
Date
Subscriber's relationship to the patient:
Secondary Insurance:
Group No.:
Policy No.:
Subscriber's Name:
First Name
Last Name
Subscriber's Social Security Number:
Subscriber's Birthdate:
-
Month
-
Day
Year
Date
Subscriber's relationship to the patient:
Emergency Contact/Next of Kin:
#1) Name:
First Name
Last Name
Relationship to patient:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Work:
#2) Name:
First Name
Last Name
Relationship to patient:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Work:
OB Pre-Admission Form
Name
First Name
Last Name
How do you prefer to be addressed?
Are you married?
Yes
No
Primary Language:
What is your level of education?
Estimated Due Date:
-
Month
-
Day
Year
Date
Is this baby up for adoption/surrogacy?
Yes
No
Are you currently in a clinical trial?
Yes
No
Are you going to be a first time parent?
Yes
No
Have you taken prenatal classes?
Yes
No
Have you been out of the country in the past 21 days?
Yes
No
Do you have a living will?
Yes
No
What is your religious denomination?
Would you like a Chaplain visit while you are here?
Yes
No
Please list any cultural or spiritual practices that would be important for staff to know:
Did you receive a nutritional consult during your pregnancy (WIC usually requires this)?
Yes
No
Would you like a dietary consult while here?
Yes
No
Do you have diabetes?
Yes
No
Have you ever had surgery?
Yes
No
*if yes, what and when?
Do you smoke?
Yes
No
*if yes, how many a day?
Do you drink alcohol?
Yes
No
*if yes, how many a week?
Do you use recreational drugs?
Yes
No
*if yes, what do you use?
Have you ever been abused?
Yes
No
Are you in a safe relationship now?
Yes
No
Do you feel safe at home?
Yes
No
Do you need to be a confidential patient for safety?
Yes
No
Do you have a history of sexually transmitted diseases?
Yes
No
*if yes, what and when?
Any problems with this pregnancy?
Yes
No
*if yes, what?
Do you receive WIC?
Yes
No
Do you give consent for baby to receive the Hepatitis B vaccine?
Yes
No
Is there a family history of hearing loss?
Yes
No
Have you ever been treated for anxiety or depression?
Yes
No
*if yes, what?
On a scale of 1-10 what is your pain tolerance?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Do you suffer from chronic pain?
Yes
No
Have you had the Flu vaccine this season?
Yes
No
*if yes, when?
If not received, would you like the Flu vaccine?
Yes
No
Have you had the Tdap vaccine booster?
Yes
No
How will you feed your baby?
Exclusive breast
Formula
Both
Pacifier?
Yes
No
Pediatrician (Select one)
Please Select
Anastasia Pediatrics (Manikal)
Ancient City Pediatrics (Bhargava & Mas)
Community Care Pediatrics (Anderson)
Pediatrics of North Florida (Ng)
Pediatrics of St. Augustine (Yasin)
On-call
Other
*if other, please specify who:
Follow-up pediatrician:
PATIENT INFORMATION& HOME MEDICATION LIST
Patient's Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
Date
Allergies:
Primary Physician:
Pharmacy (include name and location):
List ALL Medications Below - (Including Over-the-Counter/Vitamins/Herbal Supplements)
Name of Medication
Doses/Strength
How many/How often?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
FOR YOUR SAFETY, PLEASE UPDATE WHEN YOUR MEDICATIONS CHANGE. PLEASE KEEP A COPY OF THIS FORM WITH YOU.
Submit
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