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New Patient Registration Form
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1
Name
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First Name
Last Name
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2
Age
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Date Of Birth
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Date
Year
Month
Day
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3
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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United States
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
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
Please Select
Please Select
United States
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
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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4
Phone Number
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Area Code
Phone Number
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5
Emergency Contact Phone Number
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Emergency Contact
Area Code
Phone Number
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6
E-mail
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7
Relationship Status
Married
Domestic Partner
Single
Divorced
Separate
Widwed
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8
Ethnicity
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Caucasian
African American
Native American
Asian
Hispanic and Latino
Middle Eastern
Multiracial
Pacific Islands Americans
Other
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9
Employment Status
Employed Full-time
Employed Part-time
Unemployed
Disabled
Retred
Homemaker
Other
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10
Do you have any special needs we need to be aware of?
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11
Physical
*
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Please fill to the Best of your Knowledge
Height
Weight
Last Recorded Blood Pressure
Date of last physical mm/dd/yyyy
Name of Primary Care Physician
Location
List all Allergies (plants, animals, medication, etc.)
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12
Past Medical History
If none, type N/A
List year of incident(s) in order separated by comma
List treatment(s) in order separated by comma
List illnesst/operation(s) in order separated by comma
List doctor/therapist(s) in order separated by comma
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13
Describe Any Current Medical Problems:
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14
Current Medication and Dose
List all categories in order and separate by comma. If none, type N/A
Current Medication and Dose
Prescription
How often
Non-prescription
Purpose of medication
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15
Substance Use
If Not Available Put N/A
Please Select
Tobacco
Caffeine
Alcohol
Street Drug
Please Select
Please Select
Tobacco
Caffeine
Alcohol
Street Drug
Select primary
Date Last Used mm/dd/yyyy
Type (for tobacco and caffeine, type N/A)
Amount per day
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Yes
No
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Yes
No
Tried to Quit?
Any additional substances, list here
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16
Fee for Service Appointment
*
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The fee for appointments is based upon the type of appointment you have scheduled. A staff person will discuss what your fee is at the time that you schedule an appointment. Your session begins at your scheduled time, not when you arrive.
I agree
I do not agree
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17
Payment
*
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Payment will be required at the time of your appointment. The office reserves the right to send a bill for collection, after 90 days without a payment. Any questions regarding payment needs to be directed to your provider.
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18
Missed Appointments and Cancellations
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Not made at least 48 HOURS prior to the scheduled appointment will be charged $75.00 per incident. This is not covered by insurance. A list of my fees is available upon request.
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I do not agree
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19
Confidentiality
*
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All information discussed in the course of treatment is strictly confidential. By law, information can only be released with the written consent of the person treated, or such person’s parent or guardian. However, lay requires the release of confidential information in three situations: suspected child or elder abuse, potential suicidal behavior, or threatened harm to another. In addition, in certain select circumstances, the court may subpoena treatment records. The law also allows me to consult with other health care providers without your written permission if I deem it in your best interest for me to do so.
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I do not agree
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20
Ethics and Professional Standards
*
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As a licensed nurse practitioner and a member of the Washington State Nurses Association, I am accountable for my work with you. If you have any concerns about the course of treatment, please discuss them with me. Should you feel that I have been unethical and unprofessional, you may contact the Licensing Department in Olympia at 206-753-6981.
I agree
I do not agree
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21
Type of Medical Information to be disclosed
*
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HIPAA Authorization
All Medical Records
Ambulatory Clinic Records
Medical Consultations
Dental Records
Discharge Records
Emergency Records
Financial Records
Medical History & Physical Exams
Imaging Reports
Laboratory & Pathology Reports
Operation Reports
Progress Notes
Psychological Tests
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22
Other Information allowed to be disclosed
I give consent to the release of my HIV/AIDS testing information if there is any
I give consent to the release of information pertaining to drugs and alcohol
I give consent to the release of my genetic information and family background information
I give consent to the release of information pertaining to mental health diagnosis or treatment.
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23
Patient Signature
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Clear
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24
How did you hear about us?
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Facebook
Instagram
Twitter
Google
Friend Recommendation
Val-Pack
Other
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Facebook
Instagram
Twitter
Google
Friend Recommendation
Val-Pack
Other
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25
Other
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26
Suggestions if any for further improvement:
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27
Tags
Todo
In Progress
Done
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