New Patient Information

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Patient Information

Patient Name

First

Middle

Last

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Date of Birth

Marital Status

Sex

Preferred Language

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Race

Ethnicity

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Social Security Number

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Home Phone

Cell Phone

Work Phone

As required by the Health Information Portability and Accountability Act (HIPAA) you have a right to request that communications concerning your personal health information be made through confidential channels.

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Leave Messages on Voicemail?

Best way to reach you:

Leave Messages with Another Person?

Is this visit due to an auto accident or work related injury?

Primary Address

Address Line 1

City

State

Zip Code

For Minors Under 17

Mother's Name

Mother's Phone Number

Mother's Address

Father's Name

Father's Phone Number

Father's Address

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Emergency Contact Name

Physcian you are requesting:

Emergency Contact Phone

Relationship

Pharmacy Information

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Pharmacy Name

Pharmacy Phone Number

Pharmacy Type

Retail
Mail Order

Pharmacy Address

Acknowledgement of receipt of the HIPAA Notice of Privacy Practices

I acknowledge that I have read and understand the HIPAA Notice of Privacy Practices.

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Patient / Guardian Signature:

Date

Electronically Signed

I Accept

I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.