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
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 |
How Did You Hear About Us?
☐ Physician Referral: _________________
☐ Insurance Directory
☐ Internet Search
☐ Social Media
☐ Friend/Family Member
☐ Other: _________________
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.
Patient Portal
☐ I would like to enroll in the patient portal
| Field |
Entry |
| Preferred Email for Portal |
|
Signature
| Field |
Entry |
| Patient/Guardian Signature |
|
| Printed Name |
|
| Relationship (if not patient) |
|
| Date |
|
For Office Use Only
| Field |
Entry |
| Date Received |
|
| Entered By |
|
| Chart Number |
|
| Insurance Verified |
☐ Yes |
| Copay Collected |
$ |
| Notes |
|
Form FRM-OPT-001 Rev 1.0 - New Patient Registration Form
