# New Patient Registration Form

| Form ID | FRM-OPT-001 | Revision | 1.0 |
|---------|-------------|----------|-----|

---

## Patient Information

| Field | Entry |
|-------|-------|
| Last Name | |
| First Name | |
| Middle Name/Initial | |
| Preferred Name | |
| Date of Birth | |
| Age | |
| Sex | ☐ Male ☐ Female ☐ Other |
| Social Security # (last 4) | XXX-XX-_____ |

### Contact Information

| Field | Entry |
|-------|-------|
| Street Address | |
| Apartment/Unit | |
| City | |
| State | |
| Zip Code | |
| Home Phone | |
| Cell Phone | |
| Work Phone | |
| Preferred Contact Method | ☐ Home ☐ Cell ☐ Work ☐ Email |
| Email Address | |
| OK to Leave Message? | ☐ Yes ☐ No |

### Additional Information

| Field | Entry |
|-------|-------|
| Marital Status | ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Partnered |
| Race/Ethnicity (optional) | |
| Preferred Language | |
| Interpreter Needed? | ☐ Yes (Language: _______) ☐ No |
| Employer | |
| Occupation | |

---

## Emergency Contact

| Field | Entry |
|-------|-------|
| Name | |
| Relationship | |
| Home Phone | |
| Cell Phone | |
| Work Phone | |

---

## Primary Care Information

| Field | Entry |
|-------|-------|
| Primary Care Physician | |
| Practice Name | |
| Phone Number | |
| Fax Number | |
| Address | |
| Date of Last Visit | |

---

## Referring Provider (if applicable)

| Field | Entry |
|-------|-------|
| Referring Physician | |
| Practice Name | |
| Phone Number | |
| Fax Number | |
| Reason for Referral | |

---

## Insurance Information

### Primary Insurance

| Field | Entry |
|-------|-------|
| Insurance Company | |
| Policy/ID Number | |
| Group Number | |
| Policy Holder Name | |
| Policy Holder DOB | |
| Relationship to Patient | ☐ Self ☐ Spouse ☐ Child ☐ Other: _______ |
| Insurance Phone | |

### Secondary Insurance (if applicable)

| Field | Entry |
|-------|-------|
| Insurance Company | |
| Policy/ID Number | |
| Group Number | |
| Policy Holder Name | |
| Policy Holder DOB | |
| Relationship to Patient | ☐ Self ☐ Spouse ☐ Child ☐ Other: _______ |
| Insurance Phone | |

---

## Responsible Party (if different from patient)

| Field | Entry |
|-------|-------|
| Name | |
| Relationship to Patient | |
| Date of Birth | |
| Address (if different) | |
| Phone Number | |
| Email | |

---

## Pharmacy Information

| Field | Entry |
|-------|-------|
| Preferred Pharmacy Name | |
| Address | |
| Phone Number | |
| Cross Street/Location | |
| Preferred Mail Order Pharmacy | |

---

## Medical History Summary

### Current Medications
*List all current medications including over-the-counter and supplements*

| Medication Name | Dose | Frequency |
|-----------------|------|-----------|
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |

### Allergies

☐ No Known Allergies (NKA)

| Allergen | Type | Reaction |
|----------|------|----------|
| | ☐ Drug ☐ Food ☐ Other | |
| | ☐ Drug ☐ Food ☐ Other | |
| | ☐ Drug ☐ Food ☐ Other | |

### Medical Conditions
*Check all that apply*

| Condition | ☐ | Condition | ☐ |
|-----------|---|-----------|---|
| Arthritis | | Liver Disease | |
| Asthma | | Lung Disease/COPD | |
| Cancer | | Mental Health Condition | |
| Diabetes | | Seizures/Epilepsy | |
| Heart Disease | | Stroke/TIA | |
| High Blood Pressure | | Thyroid Disease | |
| High Cholesterol | | Other: _____________ | |
| Kidney Disease | | Other: _____________ | |

### Surgical History

| Surgery/Procedure | Year |
|-------------------|------|
| | |
| | |
| | |

---

## Social History

| Field | Entry |
|-------|-------|
| Tobacco Use | ☐ Never ☐ Current ☐ Former (Quit year: _____) |
| If yes, type/amount | |
| Alcohol Use | ☐ None ☐ Social ☐ Daily |
| If yes, type/amount | |
| Exercise | ☐ None ☐ Light ☐ Moderate ☐ Vigorous |
| Frequency | times per week |

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## How Did You Hear About Us?

☐ Physician Referral: _________________
☐ Insurance Directory
☐ Internet Search
☐ Social Media
☐ Friend/Family Member
☐ Other: _________________

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## Acknowledgments

### Financial Policy
☐ I have read and understand the financial policy. I authorize payment directly to this practice of any insurance benefits otherwise payable to me. I understand that I am responsible for any amount not covered by insurance.

### Privacy Practices
☐ I have received a copy of the Notice of Privacy Practices and understand how my health information may be used and disclosed.

### Release of Information
☐ I authorize the release of medical information necessary to process insurance claims and for continuity of care with referring and consulting physicians.

### Communication Authorization
☐ I authorize communication via: ☐ Phone ☐ Email ☐ Text Message for appointment reminders and health information.

### Assignment of Benefits
☐ I authorize payment of medical benefits to this practice for services rendered.

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## Patient Portal

☐ I would like to enroll in the patient portal

| Field | Entry |
|-------|-------|
| Preferred Email for Portal | |

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## Signature

| Field | Entry |
|-------|-------|
| Patient/Guardian Signature | |
| Printed Name | |
| Relationship (if not patient) | |
| Date | |

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## For Office Use Only

| Field | Entry |
|-------|-------|
| Date Received | |
| Entered By | |
| Chart Number | |
| Insurance Verified | ☐ Yes |
| Copay Collected | $ |
| Notes | |

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*Form FRM-OPT-001 Rev 1.0 - New Patient Registration Form*