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Home » New Patient Registration & Medical History Form (NYC)

New Patient Registration & Medical History Form (NYC)

New Patient Registration & Medical History Form NYC)

  • Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
  • Patient Information

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide your email address.
  • MM slash DD slash YYYY
  • Primary Insurance

  • Please bring all insurance cards with you to your appointment.
  • MM slash DD slash YYYY
  • Secondary Insurance

  • If you have coverage through another plan/organization, please fill in the details below.
  • MM slash DD slash YYYY
  • Pharmacy info

  • Enter in local and mail order pharmacy details
  • Medical History

  • Include Name of Medication, Dosage, Frequency Taken
  • Including any Eye surgeries
  • Family History

    Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
  • Please indicate which family member has the condition: Mother, Father, Child, Maternal Grandmother or Grandfather, Paternal Grandmother or Grandfather, Distant Relative
  • Social History

    This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.

    Do you currently or have you ever had any problems in the following areas?
  • Constitutional

  • Neurological

  • Eyes

  • Endocrine

  • Ears, Nose, Mouth, Throat

  • Respiratory

  • Vascular/Cardiovascular

  • Gastrointestinal

  • Genitourinary

  • Bones/Joints/Muscles

  • Lymphatic/Hematologic

  • Allergic/Immunologic

  • Psychiatric

  • Privacy Policy

  • read here our HIPAA policy
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.