Patient Registration Form

NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

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* 1. Patient name

First name

Last name

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* 2. Email

Email address

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* 3. Phone number

Country Code

Number

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* 4. Address

Street address

Street address 2

City

State

Zip Code

Country

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* 5. Date of Birth

Date

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* 6. Gender Identity

Man

Woman

Non-binary

Prefer to self-describe (please specify)

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* 7. Primary Care Physician (PCP)

First name

Last name

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* 8. Primary Care Physician (PCP) phone number

Country Code

Number

Health History

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* 9. Are you currently pregnant?

Yes

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* 10. Do you have any known allergies?

Yes (please specify)

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* 11. Have you ever had surgery?

Yes (please explain)

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* 12. Please list all current medications:

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* 13. Have you experienced any of the following medical conditions?

Acid reflux

Anxiety

Asthma

Cancer

Depression

Diabetes

Eczema

Heart attack

High blood pressure

Migraine headache

Neurological condition

Pulmonary disease

Stroke

Ulcers

Other conditions (please specify)

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* 14. Reason for patient registration

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* 15. Preferred Pharmacy

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* 16. Pharmacy Phone Number

Country Code

Number

Emergency Contact

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* 17. Emergency Contact

First name

Last name

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* 18. Relationship

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* 19. Emergency Contact Phone Number

Country Code

Number

Insurance Information

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* 20. Insurance Company

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* 21. Insurance ID

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* 22. Policy Holder's Name

First name

Last name

Consent to Release Medical Information

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* 23. Release information to:

First name

Last name

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* 24. Phone number

Country Code

Phone number

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* 25. Fax

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* 26. I consent to the release of my medical information to the individual named above:

I consent

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* 27. Signature:

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* 28. I acknowledge that by entering my name above I am providing a digital signature.

I agree

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* 29. Please enter the date below.

Date