Registration Form
Please allocate up to 30 uninterrupted minutes to complete this survey. There is not an option to save your progress and continue later.
Patient Information
Patient's Last Name *
Your answer
Patient's First Name *
Your answer
Patient's Middle Name
Your answer
Prefix
Marital status if applicable (or student)?
Is this your legal name? *
Social Security Number
XXX-XX-XXXX
Your answer
Former Name if Applicable
Your answer
Birth date *
MM
/
DD
/
YYYY
Sex
Address
Street Address *
Your answer
City *
Your answer
State *
ZIP Code *
Your answer
P.O. Box:
Your answer
Contact Info
Primary Phone Number *
(XXX)XXX-XXXX
Your answer
Cell Phone Number
(XXX)XXX-XXXX. Please provide if you would like text reminders.
Your answer
Email Address *
Your answer
Preferred contact method for appointment notifications and reminders *
Required
Pharmacy Info
Preferred Pharmacy and Location
Your answer
Pharmacy Phone Number
(XXX)XXX-XXXX
Your answer
Employment Info
Work
Occupation
Your answer
Employer
Your answer
Employer Phone Number
(XXX)XXX-XXXX
Your answer
Medicaid/Medicare Info
Are you a Medicaid Patient? *
Are you a Medicare Patient? *
Referred to Practice by:
Doctor, Healthcare Provider, Family, Friend, Functional Medical Website, Online Search, Vickie Gibbs, Ect...
Name of Referral
Your answer
Primary Care Physician (PCP)
Do you have a Primary Care Physician (PCP) *
If you have a PCP, will you continue to see your PCP for your primary care issues?
If you have a PCP, what is the name of your PCP?
Your answer
Patient/Guardian Initials *
The above information is true to the best of my knowledge. I understand that I am financially responsible for bills submitted and any balance. I also authorize Kanodia MD or insurance company to release any information required to process my claims. A copy of this signature is valid as the original. I also give my permission for a report of my evaluation, treatment and follow up evaluation to be sent to my referring physician or primary care physician. I have read this authorization section completely and I understand and accept the writing.
Your answer
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