Medical Adult Form

Adult Registration Form - Medical
* required field

Patient Information







Primary Phone Number
Secondary Phone Number



Spouse/Emergency Contact Information

Marital Status









Insurance Information

Do you have a Primary Care Doctor?

Is this visit related to an accident?


























Medical History

Are you currently being treated by a physician?



How did you hear about our Practice?
Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Do you take vitamins?

Do you smoke?


Are you interested in stopping smoking?
Do you regularly drink alcohol?
Do you drink coffee or other caffeinated beverages?
Do you exercise regularly?
(Women)

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims and to any Physician or Health Care Provider to whom I might be referred for medical reasons. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics.




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