New Patient Registration Form

Please fill out and submit this form prior to your first visit at our office. You may submit this form online or download and print the new patient paperwork to fill out by hand. If you do not have an appointment already scheduled, please indicate your preferred times and availability for an appointment, as well as the reason for the visit, in the designated space below.

CONTACT INFORMATION

Name

Telephone Number

Mailing Address

INSURANCE INFORMATION

Insurance Provider

Insurance Subscriber ID

DEMOGRAPHIC INFORMATION

Date of Birth

Gender

Marital Status

Race / Ethnicity

Primary Language

Occupation / Student Status

# of People in your Household

Emergency Contact's Name

Emergency Contact's Telephone Number

APPOINTMENT INFORMATION

When would you like to come in?

What is the primary reason for your appointment?

What else would you like to ask or add to your new patient request?

OPTIONAL INFORMATION

These are optional questions that help us improve your medical records. You may choose to answer the rest of the questions in the office when you come for your appointment, or simply decline to answer the questions below at all.

Are you disabled?

Do you wear contacts or glasses?

Do you have a hearing impairment?

Are you able to pay for your medications?

Do you currently use tobacco in any form?

Are you a former smoker?

Have you had alcohol in the past 12 months?

If yes, how often? (Days Per Week)

If yes, how many drinks per week? (# Per Week)

Do you use recreational/street drugs?

If yes, what drugs do you use?

Have you been sexually active in the last 12 months?

If yes, with which types of partners?

Do you have any history of Sexually Transmitted Disease (STD)?

Do you have an Advance Directive or Living Will?

If no, would you like information on this today?

In the last two weeks have you felt sad, depressed or hopeless?

In the last two weeks have you had little interest or pleasure in doing things you used to like to do?