New Patient Registration Form: Adult
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Demographics
Demographics
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Emergency Contact Information
Emergency Contact Information
IN CASE OF EMERGENCY, who will be notified?
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Spouse's Information
Spouse's Information
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Insurance & Pharmacy Information
Insurance & Pharmacy Information
PLEASE CONTACT YOUR INSURANCE COMPANY PRIOR TO YOUR APPOINTMENT TO VERIFY YOUR BENEFITS
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Patient History
Patient History
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Please select an option.
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Smoking/Drinking History
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ALLERGIES: MEDICATION/ENVIRONMENTAL
Past Medical History
Past Medical History
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Family History of Medical Problems
Family History of Medical Problems
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.