Initial Registration e-Forms

Personal Information

Name *

First

Last

Email *

Phone *

Date of Birth *

Sex *

Female
Male

Address

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency contact

Emergency Contact Name *

First

Last

Emergency Contact Relationship

Emergency Contact Phone *

Family Physician

Family Physician Name

Family Physician Phone

Medical history

Please check if you have any of the following

Do you have any other health problems or medical conditions?

Surgical History *

Are you a smoker?

Yes
No
Quit

Do you drink alcohol?

Yes
No

Allergies to medicines, foods, etc. *

List of medications, vitamins and supplements that you are currently taking *

Consent *

I certify that the preceding medical and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. If I willingly withhold knowledge from my treating physician, I accept full liability from any consequences arising there from.

Name *

First

Last

Signature

Date *

Patient registration and intake form

Personal Information

Address

Emergency contact

Family Physician

Medical history

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