Prattville - Health Star New Patient Forms

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)

Do You Currently or Have you Previously Smoked Tobacco/Vaped?

Yes, CurrentlyYes, PreviouslyNo, Never

Do You Drink Alcohol/How Often?

Yes, dailyYes, sometimesYes, rarelyNo, never

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: *

I am aware that I can obtain a copy of the HIPPAA policy in office.

Print Name:

First NameLast Name

Signature of Patient/Patient's Legal Guardian or Representative*

Date*

Date

New Patient Information