Patient Registration

The Patient Registration process uses

an electronic fill-in and sign form

that is encrypted for your privacy.

Forms are best completed using a

computer, laptop, tablet.

Please have handy a picture/screenshot of your

valid Driver's License, Passport, or School ID

and Insurance Card (front and back).

Be sure to click "SUBMIT" when finished.

Because we are unable to legally serve you

without certain Patient information,

failure to complete the Patient Registration forms and

submit all required information within 4 hours of booking,

may result in cancellation of your appointment

as well as forfeiture of any fees paid.

We look forward to serving your healthcare needs.

Payment Policy Consent

General Consent

Telehealth Consent

Consent for MH Treatment

Controlled Substances

Credit Card Authorization

Patient Registration

First and Middle Name

Last name

Birthday

Month

Day

Year

Mobile Phone

123-456-7890

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Gender Identity

Female

Male

Other

Valid Photo ID or Passport

Driver's License State

Driver's License #

Emergency Contact - First and Last Name

Relationship to Contact

Parent

Spouse

Friend

Other

Phone

Date of Birth

MM/DD/YYYY

Who will be financially responsible for you?

Myself

Same as Emergency Contact

Other

Other Responsible Party - First and Last Name and Date of Birth

What will be your method of payment?

Self Pay

Insurance

Join the DPC Program

Insurance Carrier

Insurance Card - Front

Insurance Card - Back

Subscription or Membership Number

Group #

Preferred Pharmacy - Name

Pharmacy Street Address & ZIP Code

Medical History:

Do you have any allergies? Please list the allergic reaction (i.e., coughing, swelling, rash, etc.)

Are you currently taking any medications? (If you are taking herbal supplements, vitamins, or over-the-counter medications, please list them as well.)

Note: For your safety, this Practice will telephone and/or request Medical Records from Patient's previous pharmacy, the Arizona Pharmacy Board, Patient's insurer, if any, and/or Patient's healthcare provider(s), if any, to confirm Patient's reported medication(s), dosages, and/or diagnoses in the absence of Patient presenting valid prescription bottle(s) prior to prescribing any medications especially controlled substance(s).

Hospitalizations or Surgeries (Reason and Date)

Lifestyle & Social History:

Weapons in the Home

Yes and Secured

Tobacco Use

Current Everyday Smoker

Former Smoker

Never Smoked

Alcohol Use

Do Not Drink Alcohol

Drink Daily

Occasional Drinker

History of Alcoholism

Do you Exercise?

Couch Potato, less than 2 days a week

Frequent, 3 to 4 days

I Love My Heartbeat, at least 5 days

Height

Feet' Inches", i.e., 5'6"

Current Weight

Pounds, Inches, i.e, 150.2

Have you Gained or Lost Weight?

Gained 25 pounds in the last six months.

Lost 25 pounds in the last six months.

Weight has been about the same over the last six months.

Water intake is about ? cups per day

Caffeine intake is ? cups per day-coffee, soda, energy drinks

Number of Meals per Day

Number of Snacks per Day

I Always Feel Hungry

Yes

and I usually Overeat

My last bowel movement/poop was

Yesterday Morning or Afternoon.

Yesterday Evening.

This Morning.

This Afternoon.

# of Bowel Movements/Poops per Day

Irregular or Every Other Day

Once Daily

Did you get the COVID-19 Vaccine(s)?

Yes

If Yes, which Type - J&J, Moderna, or Pfizer

Last Physical Exam - Month/Year

Last Blood Work/LABs - Month/Year

Last Eye Exam - Month/Year

Last Dental Exam - Month/Year

Last EKG - Month/Year

Last TB Skin Test - Month/Year

Last Colonoscopy - Month/Year

MEN ONLY: Last PSA - Month/Year

WOMEN ONLY: Last PAP Screening - Month/Year

Last Menstrual Period - Month/Year

Last Mammogram - Month/Year

Last Bone Density/DEXA Scan - Month/Year

# of Pregnancies

# of Miscarriages/Abortions

# of Living Children

By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosures/consents

Credit Card Number

XXXX-XXXX-XXXX-XXXX - Please see the Credit Card Authorization for terms of use. Submitting invalid card information may result in automatic cancellation of your appointment.

Expiration Date

MMYYYY

Security Code (CVV)

XXXX

Address where the Credit Card is Billed to

Country/Region

Address

Address - line 2

City

Zip / Postal code

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Print First, Middle, and Last Name

Today's Date

Time

HoursMinutes