New Patient Form (*** SAMPLE ONLY ***)

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THIS IS A SAMPLE PROVIDED FOR ILLUSTRATION PURPOSES ONLY

DO NOT FILL IT OUT

DO NOT SUBMIT ANY PERSONAL INFORMATION

For more information, please visit https://officeflo.health/online-forms/ or
chat with us at https://chat.officeflo.health

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

YYYY

Gender

Male

Female

Clear selection

Patient's Address *

Street Address, City, State, Zip Code

Email Address

We will use your e-mail address ONLY for communications that you approve (e.g., info about appointments, invoicing, etc.)

Mobile Phone Number

At least one phone number is required

Home Phone Number

At least one phone number is required

Work Phone Number

At least one phone number is required

Occupation

Emergency Contact

Name, Phone Number, Relationship

Contacts authorized to access patient's personal health information

Enter Full Name, Contact's Phone # and Email address

Possible ways to contact you *

Please check ALL that apply, we will use the most appropriate for the specific occasion.

SMS on your mobile phone

By e-mail

Calendar invite (for appointments only)

Voice Call - Home Phone

Voice Call - Work Phone

Voice Call - Mobile Phone

Postmail

Other:

Required

Select options for paperless billing *

Receive invoices via secure Email (Go Green!)

No paperless billing. Send invoice via USPS mail. Self addressed stamped envelope is NOT needed (e.g., will pay over phone, or via Bill Pay)

No paperless billing. Send invoice via USPS mail with a self addressed stamped envelope included (e.g., will send a check)

Clear form

Never submit passwords through Google Forms.

This form was created inside of Entrespace Group.

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