Patient Registration: Please print
this
form, fill it out and bring it with you to expedite your office visit. Please print legibly, and complete entire form.
Name----------------------------------------------------------------------------------------------------------------Today's
date------------------------
(last)
(first)
(middle)
Address:--------------------------------------------------------------------------------------------------------------------------
(street)
(city & zip)
Phone: Home----------------------Work---------------------Cell------------------------email------------------------------
Pharmacy:----------------
Date of Birth:------------------Sex------Marital Status----------Social Security#---------------------------------
Employed(y/n)------Employer's name:--------------------------------------------Full time Student?(y/n)---------
Employer's
address:----------------------------------------------------------------------------------------------------------
(street)
(city & zip)
Insurance name:--------------------------------------------------ID#------------------------------Group#---------------
if subscriber( Primary Card Holder ) is other than the patient, then list his information:
Subscriber
name:-------------------------------------------------------------------Date
of birth of the Subscriber:---------------------
Subscriber Address if different from
above:-----------------------------------------------------------------------------
Subscriber's employer(name &
address):-------------------------------------------------------------------------------
------------------------------------------------------------------
Medical Information:
Allergies to drugs:-------------------------------------------------------------------------------------------------------------
Medications currently in use:----------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------
Tobacco:# of cigs/day:---------date quit:-------------Alcohol#of drinks/week:---------Date quit:-------------
High blood pressure:(yes/no)year discovered:-----------Diabetes:(yes/no): year discovered:--------------
Asthma:(yes/no):year discovered-----------Migraine(yes/no)year discovered:---------
Cancer(type)----------------------year discovered:--------------
Other medical conditions:----------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
Family History:( Brothers/Sisters/Aunts/Uncles/Parents/Granparents only)
1. Heart attacks/bypass or stent:(relationship & age):------------------------------------------------------------------
2. Stroke:(relationship & age):-------------------------------------------------------------------------
3. Diabetes:(relationship & age):-----------------------------------------------------------------------
4. Cancer:(relationship & age):-------------------------------------------------------------------------
5. Depression:(relationship & age):---------------------------------------------------------------------
6. Alcoholism:(relationship & age):---------------------------------------------------------------------
7.Other:-----------------------------------------------------------------------------------------------
Who referred you to my practice:----------------------------------------------------------------------
Emergency Contact:--------------------------------------------------Phone:--------------------------
I,--------------------------------hereby authorize Dr.
Arthur Davida
to release any information obtained
in the course of my examination and treatment, to my insurance carrier.
I authorize my insurance benefits
to be paid directly to Dr. Arthur Davida, and I am responsible for
non covered services except the plan
discounts.
-----------------------------------------------
(Signature of patient or parent)