New Patient Form
Patient's First Name *
Your answer
Patient's Last Name *
Your answer
Patient's Date of Birth *
MM
/
DD
/
YYYY
Gender
Patient's Address *
Street Address, City, State, Zip Code
Your answer
Email Address
We will use your e-mail address ONLY for communications that you approve (e.g., info about appointments, invoicing, etc.). Unless you instruct us otherwise, we will protect the e-mail content with encryption whenever possible (no additional password for patients will be required). If you select to receive calendar invites via e-mail, you acknowledge that there is some level of risk that third parties might be able to read non-encrypted emails with calendar invites (appointment information).
Your answer
Mobile Phone Number
XXX-XXX-XXXX (At least one phone number is required)
Your answer
Home Phone Number
XXX-XXX-XXXX (At least one phone number is required)
Your answer
Work Phone Number
XXX-XXX-XXXX (At least one phone number is required)
Your answer
Occupation
Your answer
Emergency Contact
Name, Phone Number, Relationship
Your answer
Contacts authorized to access patient's personal health information
Enter Full Name, Contact's Phone # and Email address
Your answer
Possible ways to contact you *
Please number your preferred method #1 and the other methods in order of preference
Required
Select options for paperless billing *
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