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Demographics/insurance information :
First Name*:
Last Name*:
Are you a new patient?*: Yes No
Address*:
Email*:
Best contact number*:
Date of Birth (Enter in MM/DD/YYYY)*:
How did you hear about us?*:
If referred by a physician, please enter physician's name.
Who is your primary care doctor?*:
What is the address of your preferred pharmacy to pick up your medication?*:
Insurance Carrier:
Group:
Member ID:
Claims Address:
Reason for your visit*:
Height*:
Weight*:
Medical History:
Allergies (Please select all that apply)*: None Known Allergies Adhesive Tape Local Anesthetics Aspirin Penicillin Iodine / Shellfish Codeine Demerol Food Allergies Other
Please list 'Other' allergies:
Please list all medications you are currently taking. If none, enter NONE*:
Medical History - Please check all that apply*: None Blood pressure Circulatory Problems Diabetes Local anesthetic Other
Please list all Medical History you have. If none, enter NONE*:
If you are diabetic, what is your last hemoglobin A1C reading? (Enter N/A if not applicable)*:
Please list all major surgeries you've had in last 10 years. (If none, enter NONE.)*:
Have you had the flu shot this season?*:YesNo
When was your last flu shot? If not applicable, enter NA*:
Pneumonia shot – If you are over 65, have you had a pneumonia shot?*:YesNo
When was your last Pneumonia shot? (If not applicable, enter NA)*:
Are you currently smoking?*:YesNo
What is your shoe size?*:
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