New Patient Intake Form:
Eric Hamill MD
Patient Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2 /Unit no.
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Gender
Please Select
Female
Male
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Occupation
Employer
Marital Status
How did you hear about us?
Pharmacy Information
Pharmacy Name
Pharmacy Address
Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason For Consultation
What issue would you like to discuss with Dr. Hamill?
Health Information
Have you been told you have any of the following?
*
Rows
YES
NO
Comments
High Blood Pressure
Diabetes
Heat/Circulation Problems
Stroke or TIA
Bleeding Disorder
Cancer
Kidney Problems
Thyroid Problems
Mental Health condition
HIV/HCV/HBV
Any other medical problems? If yes, please describe:
*
Please list all prior surgeries and approximate dates:
*
Please list all current medications, supplements, and vitamins and their dosages:
*
Have you or anyone in your family had issues with anesthesia?
*
Please list all medication allergies and adverse reactions:
*
Are you pregnant?
*
Please Select
No
Yes
Are you breastfeeding?
*
Please Select
No
Yes
Emergency Contact
Contact in case of emergency / Next of Kin
*
First Name
Last Name
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Relationship
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Submit
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