Patient Registration Form

First Name

Please enter the First Name.

Last Name

Please enter the Last Name.

Middle Name

Street and Number (Mailing Address)

Please enter the Street and Number.

City

Please enter the City.

State

Please enter the State.

Zip Code

Please enter the Zip Code.

Home Phone

Please enter the valid Home Phone.

Mobile Phone

Please enter the Mobile Phone.

Work Phone

Please enter the valid Work Phone.

Marital Status

Patient's DOB

Please enter the DOB.

Age

Patient Sex

Please enter the Patient Sex.

Email Address

Please enter the Email Address.

Social Security #

Employer Name and Address

If patient is a minor, specify parent/guardian names

Specify relation to patient

Primary Language

Primary Care Physician

Please enter the Primary Care Physician.

Referring Physician

Name of the emergency contact person

Please enter the Emergency Contact Name.

Relationship

Home Phone

Mobile Phone

Insurance Information

Name of primary insurance

Policy subscriber's name, if not patient

Subscriber's DOB

Patient relation to subscriber

Other Information

Pharmacy Name

Pharmacy Location

Pharmacy Phone

Drug Allergy Form

Allergy

Reaction

Allergy	Reaction	Remove

Current Medications

Medication

Past Medical Problems

Past Medical Problem

Surgeries

Surgery

Year

Surgery	Year	Remove

Tobacco Usage

None

Current Use

Prior Use

Alcohol Use

Yes

Health Maintenance Records

Exam Name	Yes or No	Date
Angiogram	Yes No Please select any one of the options.
Bone Density	Yes No Please select any one of the options.
Breast Exam	Yes No Please select any one of the options.
Colonoscopy	Yes No Please select any one of the options.
CR C1	Yes No Please select any one of the options.
Fasting Glucose	Yes No Please select any one of the options.
HGAIC	Yes No Please select any one of the options.
HH	Yes No Please select any one of the options.
Flu Vaccine	Yes No Please select any one of the options.
LAB	Yes No Please select any one of the options.
Pneumonia Vaccine	Yes No Please select any one of the options.

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT

I have received the Notice of Privacy Practice and I acknowledge that I had an opportunity to review it.

PATIENT PAYMENT POLICY

Please read the following very carefully. Your signature below will signify your agreement with and acceptance of this policy. Payment in full is expected at the time of services and rendered. If your insurance company requires a referral / prior approval or authorization, we will need it at the time of service or you must reschedule your appointment. In certain instances insurace companies may send you a check meant for ID Consultants, Inc. and if so please mail it to our office. If you fail to do so we will take further actions.

Appointments must be cancelled 24 hours in advance or there will be $50 charge.

HIPAA DISCLAIMER: I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Responsible Party:

Date