New Patient Medical & Health History Form

New Patient Medical & Health History Form

LIFETIME INSIGHT, LLC
This form will ask about your health history, including your medications, allergies, medical and surgical history, family and psychiatric history, social background, and more. We’ll also ask for your primary care doctor’s contact info and a few basic demographic details to verify your identity.

Before you start, please grab your pill bottles (including vitamins and supplements) and have your pharmacy’s name, phone number, and address ready. We don’t send prescriptions to local CVS pharmacies (sorry — no exceptions), and we can’t send to mail-order pharmacies at your first visit. Also, 90-day prescriptions won’t be approved unless you’ve been stable on your dose with us for at least two months.

Full Name*

PrefixFirst NameLast NameSuffix
How did you find us?*
Please help us learn your secret to finding great care!
Name of referring doctor/therapist
Date of Birth*

MonthDayYear
Date
Age*
Picture of Your Drivers License or State ID to verify identity*
Take a Selfie for our Medical Records*
Patient's SS#*
Biological Sex*

MaleFemale
Gender Identity*

MaleFemaleTranssexual MaleTranssexual FemaleNon-binaryOther
Mobile Phone*
Email*
Do you agree to receive reminders by email and text?*
NOTE: If you choose "No", we have the right to refuse to provide treatment. Please see office policies.
Home/Residential Address*

Address

Line 2

CityState

Zip Code
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
Primary Care Clinician
Please provide as we like to coordinate care
Primary Care Clinician Phone Number
Neurologist, if any
Please provide as we like to coordinate care
Preferred Pharmacy Name*
WE DO NOT WORK WITH CVS
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Pharmacy Phone Number*

Area CodePhone Number

Reason for Visit