266 lines
5.4 KiB
Markdown
266 lines
5.4 KiB
Markdown
# New Patient Registration Form
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| Form ID | FRM-OPT-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Last Name | |
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| First Name | |
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| Middle Name/Initial | |
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| Preferred Name | |
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| Date of Birth | |
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| Age | |
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| Sex | ☐ Male ☐ Female ☐ Other |
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| Social Security # (last 4) | XXX-XX-_____ |
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### Contact Information
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| Field | Entry |
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|-------|-------|
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| Street Address | |
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| Apartment/Unit | |
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| City | |
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| State | |
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| Zip Code | |
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| Home Phone | |
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| Cell Phone | |
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| Work Phone | |
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| Preferred Contact Method | ☐ Home ☐ Cell ☐ Work ☐ Email |
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| Email Address | |
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| OK to Leave Message? | ☐ Yes ☐ No |
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### Additional Information
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| Field | Entry |
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|-------|-------|
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| Marital Status | ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Partnered |
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| Race/Ethnicity (optional) | |
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| Preferred Language | |
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| Interpreter Needed? | ☐ Yes (Language: _______) ☐ No |
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| Employer | |
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| Occupation | |
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## Emergency Contact
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| Field | Entry |
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|-------|-------|
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| Name | |
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| Relationship | |
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| Home Phone | |
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| Cell Phone | |
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| Work Phone | |
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## Primary Care Information
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| Field | Entry |
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|-------|-------|
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| Primary Care Physician | |
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| Practice Name | |
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| Phone Number | |
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| Fax Number | |
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| Address | |
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| Date of Last Visit | |
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## Referring Provider (if applicable)
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| Field | Entry |
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|-------|-------|
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| Referring Physician | |
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| Practice Name | |
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| Phone Number | |
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| Fax Number | |
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| Reason for Referral | |
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## Insurance Information
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### Primary Insurance
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| Field | Entry |
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|-------|-------|
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| Insurance Company | |
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| Policy/ID Number | |
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| Group Number | |
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| Policy Holder Name | |
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| Policy Holder DOB | |
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| Relationship to Patient | ☐ Self ☐ Spouse ☐ Child ☐ Other: _______ |
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| Insurance Phone | |
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### Secondary Insurance (if applicable)
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| Field | Entry |
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|-------|-------|
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| Insurance Company | |
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| Policy/ID Number | |
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| Group Number | |
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| Policy Holder Name | |
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| Policy Holder DOB | |
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| Relationship to Patient | ☐ Self ☐ Spouse ☐ Child ☐ Other: _______ |
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| Insurance Phone | |
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## Responsible Party (if different from patient)
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| Field | Entry |
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|-------|-------|
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| Name | |
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| Relationship to Patient | |
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| Date of Birth | |
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| Address (if different) | |
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| Phone Number | |
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| Email | |
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## Pharmacy Information
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| Field | Entry |
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|-------|-------|
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| Preferred Pharmacy Name | |
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| Address | |
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| Phone Number | |
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| Cross Street/Location | |
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| Preferred Mail Order Pharmacy | |
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## Medical History Summary
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### Current Medications
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*List all current medications including over-the-counter and supplements*
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| Medication Name | Dose | Frequency |
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|-----------------|------|-----------|
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### Allergies
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☐ No Known Allergies (NKA)
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| Allergen | Type | Reaction |
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|----------|------|----------|
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| | ☐ Drug ☐ Food ☐ Other | |
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| | ☐ Drug ☐ Food ☐ Other | |
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| | ☐ Drug ☐ Food ☐ Other | |
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### Medical Conditions
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*Check all that apply*
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| Condition | ☐ | Condition | ☐ |
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|-----------|---|-----------|---|
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| Arthritis | | Liver Disease | |
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| Asthma | | Lung Disease/COPD | |
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| Cancer | | Mental Health Condition | |
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| Diabetes | | Seizures/Epilepsy | |
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| Heart Disease | | Stroke/TIA | |
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| High Blood Pressure | | Thyroid Disease | |
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| High Cholesterol | | Other: _____________ | |
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| Kidney Disease | | Other: _____________ | |
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### Surgical History
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| Surgery/Procedure | Year |
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|-------------------|------|
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## Social History
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| Field | Entry |
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|-------|-------|
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| Tobacco Use | ☐ Never ☐ Current ☐ Former (Quit year: _____) |
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| If yes, type/amount | |
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| Alcohol Use | ☐ None ☐ Social ☐ Daily |
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| If yes, type/amount | |
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| Exercise | ☐ None ☐ Light ☐ Moderate ☐ Vigorous |
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| Frequency | times per week |
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## How Did You Hear About Us?
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☐ Physician Referral: _________________
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☐ Insurance Directory
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☐ Internet Search
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☐ Social Media
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☐ Friend/Family Member
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☐ Other: _________________
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## Acknowledgments
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### Financial Policy
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☐ 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.
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### Privacy Practices
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☐ I have received a copy of the Notice of Privacy Practices and understand how my health information may be used and disclosed.
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### Release of Information
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☐ I authorize the release of medical information necessary to process insurance claims and for continuity of care with referring and consulting physicians.
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### Communication Authorization
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☐ I authorize communication via: ☐ Phone ☐ Email ☐ Text Message for appointment reminders and health information.
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### Assignment of Benefits
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☐ I authorize payment of medical benefits to this practice for services rendered.
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## Patient Portal
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☐ I would like to enroll in the patient portal
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| Field | Entry |
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| Preferred Email for Portal | |
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## Signature
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| Field | Entry |
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| Patient/Guardian Signature | |
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| Printed Name | |
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| Relationship (if not patient) | |
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| Date | |
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## For Office Use Only
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| Field | Entry |
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|-------|-------|
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| Date Received | |
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| Entered By | |
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| Chart Number | |
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| Insurance Verified | ☐ Yes |
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| Copay Collected | $ |
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| Notes | |
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*Form FRM-OPT-001 Rev 1.0 - New Patient Registration Form*
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