Patient Registration/Insurance Form PATIENT REGISTRATIONName First Last SexEmail Birth Date MM slash DD slash YYYY Current AgeSocial Security#Street Address Street Address City State / Province / Region ZIP / Postal Code Mailing Address Same as Street Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneMay we leave personal health care info, such as test results, on your voice mail?Work PhoneOccupation (If retired, please list former occupation)Please list an Emergency contact Full Name RelationshipPhoneWho Referred You to Us:Who is your Primary Care Physician:PhoneWhat Pharmacy do you prefer:TODAY'S DATE: MM slash DD slash YYYY Person to share medical info with:RaceEthnicityEmail What is your preferred language?PRIMARY INSURANCECo-Pay:Insurance Company nameID#Subscriber's NameSocial Security #Group #Subscriber's Birth Date MM slash DD slash YYYY SECONDARY INSURANCEInsurance Company nameID#Subscriber's NameSocial Security #Group #Subscriber's Birth Date MM slash DD slash YYYY Please Download the Privacy Notice Here Please Download the Financial Policy Here MEDICATIONSCURRENT MEDICATIONSNON-PRESCRIPTION MEDICINESPlease List Name of Medicine, Dose in MG and How many times a day:Please List Name of the NON-PRESCRIPTION Medicine, Dose in MG and How many times a day:Do you take GLP-1, autoimmune or similar weight loss medications? Yes No Do you take blood thinners or daily aspirin? Yes No ALLERGIES TO MEDICINESNAME OF ALLERGIC MEDICINEWrite Down TYPE OF ALLERGIC REACTION, OTHER ALLERGIES? LATEX? IODINE? TAPE?CURRENT SMOKER or tobacco user?FORMER SMOKER?NEVER SMOKED?As a patient at our office, we would like to inform you that your total health is important to us. Notice to all our new and existing patients: If you are a current tobacco user, we are obligated to inform you that smoking is harmful to your health and inhibits wound healing. For best results after surgery, it is recommended that you seek help with smoking cessation prior to any surgery. Please consult with your primary care doctor for assistance and resources with smoking cessation.
