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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.
  • Date Format: MM slash DD slash YYYY
  • Primary Insurance

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

  • If you have coverage through another plan/organization, please fill in the details below.
  • Date Format: 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
    AOK
  • 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.
  • REVIEW OF SYSTEMS

    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
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.