Patient Registration Form

Patient Information

Patient First Name

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Patient Last Name

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Patient Phone Number:

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Alternate Phone:

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Is this a work or cell phone number?

Work

Cell Phone

Social Security Number:

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Address Line One:

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Address Line Two:

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State:

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Zip Code:

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Date of Birth:

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Gender:

Male

Female

Prefer Not to Say

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Marital Status:

Married

Single

Divorced

Widowed

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Race:

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Other:

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Ethnicity: Do you identify with an ethnic origin? If yes, please note:

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Number of Children:

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Children Names:

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Childrens Age

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Employment Information

Employment Status:

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Other:

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Patient's Employer:

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Employer Phone Number:

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Emergency Contacts

Emergency Contact:

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Relationship to Patient:

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Address:

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Phone Number:

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Emergency Contact:

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Relationship to Patient:

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Address:

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Phone:

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Insurance Information

Primary Insurance

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Secondary Insurance:

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Is the patient the subscriber or policy holder to the Primary Insurance?

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Is the patient the subscriber or policy holder to the Secondary Insurance?

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INSURED PATIENTS (IF OTHER THAN PATIENT) - We will request to scan your ID and insurance card.

Subscriber / Policy Holder Name:

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Relationship to Patient:

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Address:

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Social Security Number

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Date of Birth:

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Their employer:

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Work Phone Number:

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Medical Information

Please list any MEDICATIONS you are currently taking, prescribed or over the counter:

Please list any MEDICATIONS you are currently taking, prescribed or over the counter, per line: (name of medication, dosage, frequency)

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Any ALLERGIES to Medications or Food, per line: (allergy, reaction)

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Preferred Pharmacy

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Date of Last Complete Physical Exam:

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Date of Last Blood Work:

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Date of Last Colonoscopy:

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Date of Last Tetanus Shot:

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This following section is for FEMALES ONLY:

Date of Last Menstrual Period:

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Date of Last Pap Smear:

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History of Abnormal Pap Smear: (Y/N). If yes, please list dates:

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Date of Last Mammogram:

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DEXA:

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Number of Pregnancies:

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Miscarriages:

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Terminations:

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Living Children:

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Method/s of Contraception:

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If YOU or a FAMILY MEMBER has had any of the following, please select and indicate in the field below which family member/s:

ADD / ADHD

Anemia

Allergies / Hay Fever

Asthma

Arthritis

Anxiety / Depression

Alcoholism

Blood Clots

Cancer

Respiratory Diseases

Stomach / Colon Disease

Stroke

Seizure Disorder

Thyroid Disorder

Other

If other, please elaborate:

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Please indicate which family member, or yourself, suffers from which disease:

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Skin Diseases

Per line, please list any SURGERIES you have had and include the month & year:

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Social Information

Tobacco Use

Do you smoke?

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If yes, how many cigarettes / cigars per day:

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Do you chew tobacco?

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Number of Years Smoking:

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Have you thought about quitting?

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Have you quit before?

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If yes, for how long did you quit?

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Alcohol Use

Do you drink alcohol?

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How many in a week?

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If so, what type?

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Drug Use

Any history of illegal drug use?

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If yes, what type/s?

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When?

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Additional Social Information

Do you exercise?

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What activities do you do, and how often in 1 WEEK:

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Do you use any caffeinated products?

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If yes, what type/s and how much per day?

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Have you recently experienced an increase in sadness?

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Have you lost interest in enjoyable activities?

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Do you have a living will? If yes, please provide us a copy

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Scheduling Policy

Dr. Silverstein & Associates reserves the right to charge a fee for any scheduled visits that are missed without calling a cancel (no-show)

Patient / Parent or Guardian Signature:

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Date:

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If personal representative is signing, please provide a description of personal representatives authority:

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Please sign your name in the area below

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.

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