New Patient Registration Form

Name *

First

Last

Date of Birth *

Email *

Phone Number *

Mailing Address *

Insurance Provider *

Subscriber ID

Gender *

Marital Status *

Race/ Ethnicity *

Primary Language *

Occupation/ Student Status *

Number of People in the Household *

Emergency Contact's Name *

Emergency Contact's Relationship to Patient *

Emergency Contact's Telephone Number *

Preferred Pharmacy *

Preferred Pharmacy Address/ Phone Number *

What is the primary reason for your appointment? *

What else would you like to ask or add to your new patient request?

Are you disabled?

Do you wear contacts or glasses?

Do you have a hearing impairment?

Are you able to pay for your medications?

Do you currently use tobacco in any form?

Are you a former smoker?

Have you had alcohol in the past 12 months?

If yes, how often? (Days Per Week)

If yes, how many drinks per week? (# Per Week)

Do you use recreational/street drugs?

If yes, what drugs do you use?

Have you been sexually active in the last 12 months?

If yes, with which types of partners?

Do you have any history of Sexually Transmitted Disease (STD)?

Do you have an Advance Directive or Living Will?

If no, would you like information on this today?

DropdownIn the last two weeks have you felt sad, depressed or hopeless?

In the last two weeks have you had little interest or pleasure in doing things you used to like to do?