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New Patient Registration Form
Get new patient records with this new patient registration form online. Fast registrations will make your life easier.
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HIPAA
Compliance
Language
English (US)
Spanish (Latin America)
1
Patient Name
*
This field is required.
First Name
Middle Name
Last Name
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2
Address:
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Date of Birth
*
This field is required.
-
Month
Day
Year
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4
Date of Evaluation
*
This field is required.
Please enter today's date.
-
Date
Year
Month
Day
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5
Referred By:
*
This field is required.
First Name
Last Name
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6
Parent/ Guardian Name
*
This field is required.
First Name
Last Name
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7
Parent Email Address
*
This field is required.
If you do not have an email address please enter 00000.
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8
Primary Language Spoken
*
This field is required.
English
Spanish
Other
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9
Patient Sex
*
This field is required.
Please Select
Male
Female
N/A
Please Select
Please Select
Male
Female
N/A
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10
Primary Concern for Appointment
*
This field is required.
Sick Visit
Injury
Sore throat, ear pain
Fever
Vomiting
Both
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11
Pediatrician's Name
*
This field is required.
First Name
Last Name
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12
What is the name of the hospital where the patient was born?
*
This field is required.
Please list the name of the hospital.
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13
What was the mother's length of pregnancy with the patient?
*
This field is required.
Please select the most applicable length of time.
37-40 weeks
30-36 weeks
25-29 weeks
25 < weeks
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14
Was the mother's labor:
*
This field is required.
Spontaneous
Induced
Vaginal
C-Section
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15
Were any medications or drugs used during the pregnancy?
*
This field is required.
YES
NO
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16
If yes, which medications or drugs were used?
*
This field is required.
Please enter N/A if not applicable.
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17
Patient's birth weight (pounds)
*
This field is required.
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18
Did any of the following complications apply at time of birth?
*
This field is required.
Check all that apply.
Jaundice
Prolonged Stay at NICU
Low birth weight
Blue color
Respiratory Difficulties
Sucking/Swallowing difficulties
Infection of baby or mother
Breech Birth
Failed NBHS
Nuchal Cord
AIDS/ HIV
Heart/Cardiovascular
Low APGAR SCORE
CMV
None of these
Other
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19
Has the patient experienced any of the following medical complications?
*
This field is required.
Check all that apply.
AIDS/HIV
Autism
Asthma
Allergy/Sinus Problems
Developmental Delay
Short Attention Span
Measles
Tonsilitis
Scarlet Fever
Gastrointestinal Problems
ADHD/ ADD
Blood Disorder
Cancer
Chicken Pox
Genetic Disorders
Diabetes
Influenza
Meningitis
Malaria
Speech Delay
Endocrine System Disorder
Physical Impairment
Headaches
Head Injury
Hearing Loss
Heart Problems
Ear Infections
Behavioral Disorder
Vision loss
UTI
Stroke
Neurologic Disorder
Learning Disability
None of these
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20
Additional Medical History/Symptoms
*
This field is required.
Please list all illnesses, past and current that have not already been listed. Please write N/A if this question is not applicable.
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21
Does the patient have food or drug allergies?
*
This field is required.
YES
NO
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22
Is the patient currently taking any medication?
*
This field is required.
Yes
No
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23
If yes, please list it here
*
This field is required.
Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma. Please write N/A if this question is not applicable.
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24
If yes, please list all food allergies.
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25
Has the patient ever had an ear infection?
*
This field is required.
YES
NO
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26
Has the patient ever had PE Tubes?
*
This field is required.
YES
NO
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27
Is the patient currently enrolled in school?
*
This field is required.
YES
NO
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28
If so, what school does the patient attend?
*
This field is required.
Please enter the school's full name.
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29
What grade is the patient currently in?
*
This field is required.
Write N/A if not applicable.
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30
Has the patient ever had an IEP?
*
This field is required.
YES
NO
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