Established Patient Registration Form

Name *

First

Last

Date of Birth *

Email *

Phone Number *

Mailing Address *

Insurance *

Subscriber ID

Gender *

Marital Status *

Race/ Ethnicity *

Primary Language

Other, List Below

Occupation/ Student Status *

Number of People in the Household, including yourself *

Emergency Contact's Name *

Emergency Contact's Relationship to Patient *

Emergency Contact's Telephone Number *

Preferred Pharmacy *

Preferred Pharmacy's Address and Phone Number *

What is the Primary Reason for your Appointment? *

Other, List Below

What else would you like to ask or add to your appointment request?

Are You disabled?

Do you wear contacts or glasses?

Do you have a hearing impairment?

Are you able to pay for your medications?

Do you currently use tobacco in any form?

If yes, what type, how many packs per day and # of years

Are you a former smoker?

If yes, when did you stop?

Have you had alcohol in the past 12 months?

If yes, how often? (# of days per week)

Do you use recreational/ street drugs?

If yes, what drugs do you use?

Have you been sexually active in the last 12 months?

If yes, what type of partners?

Do you have any history of Sexually Transmitted Infections (STI)?

Do you have an Advanced Directive or Living Will?

If No, would like information on this today?

In the last two week, have you felt sad, depressed or hopeless? *

In the last two weeks, have you have little interest or pleasure in the things you used to like to do? *

Phone