New Patient Registration

New Patient Registration Form
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Now (Hidden)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Reason for Visit
Requested Physician
Social Security Number
Gender
Marital Status

Other
Address

Street

Street Address Line 2

CityState

Zip
Race
Ethnicity
Preferred Language

Other
Upload a copy of your driver's license or other photo ID.

Browse Files
You may also email this to info@fpevans.com if you have trouble uploading here. Cancelof
ID Card Not Uploaded
- Cell Phone
  
  Area CodePhone Number
- Work Phone
  
  Area CodePhone Number
- Home Phone
  
  Area CodePhone Number
- Preferred Phone
- May we leave detailed voicemails for you?
- Email
  example@example.com
- Emergency Contact
- Relationship to Pt
- Phone Number
  
  Area CodePhone Number
- May we speak to your emergency contact about your healthcare?
- Please list the names of anyone else we may speak with about your healthcare.
  Family, Friends, Caregivers, etc
- Do you have active health insurance?
- Primary Insurance
- Primary ID #
- Secondary Insurance
- Secondary ID #
- Upload photos of your insurance card(s) - front and back.
  
  Browse Files
  You may also email this to info@fpevans.com if you have trouble uploading here. Cancelof
- Insurance Card Not Uploaded:
- Guarantor Name
  Name of subscriber on insurance/Financially responsible party
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Relationship to Pt
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone
  
  Area CodePhone Number
- Policy Agreement
- Please check all of the boxes to indicate your acknowledgement of these important points from our policies.
- Signature
  
  Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Health History
- Allergies
  Please list the allergen and your reaction to it.
- List any hospitalizations and/or surgeries.
  List dates and reasons for each.
- Current Medication List (REQUIRED: You must include dosages,frequency and reason.)
  REQUIRED: List dosage, frequency, and reason for each medication.
- Local Pharmacy
  Name, Location, and Phone Number Required
- Mail Order Pharmacy
  Name, Location, and Phone Number Required
- Current Medical Problems
  
  Other
- Previous Primary Care Doctor
  Name and Location
- Cardiologist
  Name and Location
- Dermatologist
  Name and Location
- Endocrinologist
  Name and Location
- Gynecologist
  Name and Location
- Oncologist
  Name and Location
- Ophthalmologist
  Name and Location
- Urologist
  Name and Location
- Any other providers?
  Name and Location
- For each of the following services, please provide a date, location, provider, and a result to the best of your knowledge.
- Colonoscopy
  Date, Location, Provider, and Result
- Pap Smear
  Date, Location, Provider, and Result
- Mammogram
  Date, Location, Provider, and Result
- PSA (Prostate Check)
  Date, Location, Provider, and Result
- DEXA (Bone Density Test)
  Date, Location, Provider, and Result
- Eye Exam
  Date, Location, Provider, and Result
- Pneumonia Shot
  Date, Pneumovax or Prevnar?
- Flu Shot
  Date
- Shingles Shot - Shingrix
  Date
- Shingles Shot -Zostavax
  Date
- Tetanus Shot
  Date
- COVID Vaccine
  Dates and Location
- Family History
  
  Other
- Who in your family was/is affected by breast cancer?
- Who in your family was/is affected by high cholesterol?
- Who in your family was/is affected by diabetes?
- Who in your family was/is affected by a heart attack?
- Who in your family was/is affected by heart problems?
- Who in your family was/is affected by a stroke?
- Who in your family was/is affected by colon cancer?
- Who in your family was/is affected by prostate cancer?
- Who in your family was/is affected by osteoporosis?
- Who in your family was/is affected by anxiety/depression?
- Who in your family was/is affected by psychological, drug, or alcohol problems?
- Who in your family was/is affected by high blood pressure?
- Tobacco/Nicotine Use Status
- How much and how often do you use tobacco (or nicotine)?
  1 pack per day
- Interested in quitting?
- How much and how often do you drink alcohol?
- Tell us about your exercise routine (type and frequency).
- Who lives with you in your home?
- Do you have children? What are their names and ages?
- Occupation
- Employer
- Employment Status
  
  Other
- What are your hobbies?
- How did you hear about our practice?
- Do we currently see any of your family members?
- Should be Empty:

New Patient Registration Form

Policy Agreement

Health History