Prattville - Health Star New Patient Forms

New Patient Information

Please fill in your information below. Please Note that fields with red asterisk's * are required.
Name

First NameMiddle InitialLast Name
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
E-mail:
Date of Birth:

MonthDayYear
Insurance Carrier:
Contract #:
Group #:
Sex:
Marital Status:
Social Security Number:
SSN
Referred By:
Family/Friend's Name
Occupation
Primary Care Provider:
Emergency Contact Name:

First NameLast Name
Emergency Contact Number:

Area CodePhone Number
Relationship:
Reason For Your Visit Today?
Health History & Present Symptoms (Check all that apply)

Other
Do You Currently or Have you Previously Smoked Tobacco/Vaped?
Do You Drink Alcohol/How Often?
Family Health History:
Current Medications & Reason for Taking:
This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. Please check to indicate you have been made aware of its availability:
Print Name:

First NameLast Name
Signature of Patient/Patient's Legal Guardian or Representative
Date

MonthDayYear
Date

Name of Individual/Provider/Group that I Authorize to Send Medical Records if Requested:

First NameLast Name
Phone Number:

Area CodePhone Number
Name of Individual/Provider/Group that I Authorize to Send Medical Records if Requested:

First NameLast Name
Phone Number

Area CodePhone Number
Signature
Date

MonthDayYear
Date

New Patient Information