We would like to welcome you and your child to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.

Patient Information

Primary Care Physician

Primary Insurance

It is your responsibility to inquire and bring your referral to each appointment.

Secondary Insurance

HIPPA INFO

Instructions for the office when returning phone calls or reminding you about appointments. I authorized the office to contact me at:

You may leave messages at:

I authorize the office to leave detailed messages about appointments / phone calls:

Authorization and Consent: I authorize the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I also authorize insurance payment be made directly to the physician. I give consent for evaluation and treatments, including testing and medical treatments for me or my dependent. I understand shall there be a problem or denial from my insurance company that I remain responsible for all services rendered.

*Please be as specific, truthful and accurate as possible.

Current Medical Problems/Symptoms

Do not enter previous problems here

Do you stop Breathing?

Previous Medical Problems

Please elaborate on the side

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Past Medical History

FEMALES PLEASE COMPLETE

Pregnant?
Planned Pregnancy?
Menstrual Flow
Pregnancies
Abortions
Miscarriages
Live Births

Flushing/Menopause

Previous or Recent Surgeries

Medication List

List all medications including over the counter, eye drops & herbal remedies















Immunizations

Have you had any of the vaccines below? If yes, please tell us when and how many doses in the past?

Haemophilus B

Hepatitis A

Hepatitis B

Human Papilloma Virus (HPV)

Influenza

Measles/Mumps/Rubella (MMR)

Meningococcal

Pneumonia

Tetanus

Varicelle (Chicken Pox)

Zoster (Shingles)

Allergy List

Check all that apply and Please Indicate Nature of Allergic Reaction. Ex. Hives, rash




Other Allergies (Food or Environmental)


Family History of Medical Problems

Check all that apply

Alcoholism

Asthma

Cancer

Diabetes

Epilepsy

Glaucoma

Hair Loss

Heart Disease

High Blood Pressure

Kidney Disease

Mental Illness

Migraine

Osteoporosis

Stroke

Thyroid Disease

Bleeding Disorder

Other

Social History

Alcohol

Levels of Education Completed

Domestic Violence:
Partner

Human Verification

Please click on the human verification checkbox before submitting your form.