On-line Patient Registration Form
Appointment with doctor  
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PATIENT INFORMATION
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First Name *
Middle Initial
Last Name *
Sex   
M F
Date of Birth*

(mm-dd-yyyy)
 
Social Security #

Example-123456789
Email Address
Phone    *
Cellphone   
 
Street
City
State
Zipcode
Marital Status Single Married Other               Patient Status Employed Full-Time Student Part-Time Student
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BILLING INFORMATION
Please enter information for the financially responsible party for this patient.
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Check if the billing information is same as above
First Name *
Middle Initial
Last Name *
 
Street
City
State
Zipcode
Social Security #

Example-123456789
Email Address
Phone    *
Cellphone   
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INSURANCE INFORMATION –
Self-Pay
Primary Insurance Information
Primary Insurance Name   
Subscriber ID   
Group #.   
First Name
Middle Initial
Last Name
Date of Birth

(mm-dd-yyyy)
Employer's Name
Please select the patient's relationship to the person who has this insurance   Self Spouse Child Other
 
Secondary Insurance Information (If applicable)
Secondary Insurance Name   
Subscriber ID   
Group #.   
First Name
Middle Initial
Last Name
Date of Birth

(mm-dd-yyyy)
Employer's Name
Please select the patient's relationship to the person who has this insurance   Self Spouse Child Other
 
Emergency Notification Person to Notify: Relationship to you: Phone:
Name of Primary Care Physician (PCP): Phone:
Check here if you have no PCP
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CHECK IF THIS INJURY WAS RELATED TO AN ACCIDENT.
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PAST MEDICAL HISTORY
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                            Select No Detail Below
Ear, Nose, Throat Problem Yes      No
Coronary Artery Disease Yes      No
High Blood Pressure Yes      No
Lung Disease Yes      No
Kidney/Liver Disease Yes      No
Stomach/Intestinal Disease Yes      No
Arthritis Yes      No
Diabetes Yes      No
Epilepsy Yes      No
Infections(inlcuding TB) Yes      No
Cancer Yes      No
Vascular Disease Yes      No
Psychiatric Problems Yes      No
Fibromyalgia Yes      No
Chronic Pain Yes      No
History of DVT Yes      No
History of RSD Yes      No
Posterior Tibial Tendon Disease Yes      No
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SOCIAL HISTORY
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Alcohol Use Never  Yes      How Much         No      When quit     
Drug Use Never  Yes      How Much         No      When quit     
Tobacco Use Never  Yes      How Much         No      Amount Used Prior to Quitting
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Allergies
Are you Allergic to any medication Yes No
Hospitalization (Please List) Surgeries (Please List surgery type and year)
Name Year Explain
Add Row
Name Year Explain
Add Row
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SYMPTOM REVIEW
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                            Select No Explain
Headache/Visual Changes/Dizziness Yes      No
Throat Problem/Runny Nose Yes      No
Chest pain Yes      No
Shortness of Breath/Cough Yes      No
Leg Swelling Yes      No
Heartburn/Nausea/vomiting/diaarrhea Yes      No
Burning/frequent Urination Yes      No
Loss of sensation Yes      No
Low Back pain Yes      No
Fear/chills/sweats/fatigue Yes      No
Weight gain or loss Yes      No
Troubler sleeping Yes      No
Dietary Restriction Yes      No
Please select YES only if you have read and reviewed the above information and believe it to be correct!