New Patient Paperwork

Please carefully read and complete all relevant form fields.

Patient Information

First Name

Middle Name

Last Name

Birthday

Month

Day

Year

Gender

Address

Main Phone Number

Alternate Phone Number

Employer And Occupation

Marital Status

Emergency Contact

Emergency Contact Phone Number

Emergency Contact Alternate Phone Number

Emergency Contact Relationship To Patient

Insurance Information

Self-pay / no-insurance

Insurance Carrier

Policy Number

Group Number

Secondary Insurance Carrier

Secondary Insurance Policy Number

Secondary Insurance Group Number

Patient is guarantor/insurance policy holder

*If patient is not the guarantor please fill out the information below.

Guarantor First Name

Guarantor Last Name

Relationship To Patient

Guarantor Birth Date

Guarantor Address

Guarantor Phone Number

Primary Care Physician

Primary Care Physician Phone Number

Assignment of Benefits and Authorization to Release Medical Information

I request that payment of authorized benefits of my Insurance Carrier be made on my behalf to the provider listed on this form for any services furnished to me by the provider. I authorize any holder of medical information about me to release it to the listed insurer(s), and/or agents of these companies, and/or the listed responsible person(s), any information needed to determine these benefits or the benefits for other related services.

Signature

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Patient History

Please complete all fields to the best of your ability.

If the prompt is not relevant to you; may leave blank or write N/A.

What is the reason for your visit?

Did anyone refer you?

Please list any physicians or practitioners currently involved in your care:

Do you have any known food allergies or sensitivities? List and describe how you feel when you eat them:

Do you have any drug allergies? List and explain reaction:

Please list all current medications including name, dosage, and frequency (include over-the-counter, prescription, and herbal supplements):

Please list any past or present medical illnesses:

Please list previous surgeries and hospitalizations including the date of occurrence:

Date of last chest x-ray:

Date of last EKG

Date of last allergy test:

Family History

Please list all serious illnesses in your immediate family including their name and relation to you (diabetes, heart disease, high blood pressure, asthma, etc.):

Fowler Allergy

New Patient Paperwork

Patient Information

Insurance Information

Patient History

Family History