New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY Zip Code

Home Phone:		Work Phone:
Cell Phone:		Email
SSN		Occupation
Birthday		Guardian Name
Sex	Male Female	What is your employment Status?	Employed Full-Time Student Part-Time Student
What is your marital status?	Unknown Single Married Separated Divorced Widowed Child	Where do you work/go to school?
Which Doctor are you seeing?	No Doctor Assigned Dr. Jeff Hilovsky Dr. Hayley Sprague Dr. Aimee Parker Dr. Mike Rebarchik Dr. Myloan Nguyen

Billing Information

Check box and complete if billing address is different:

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP- MDCR COMPLETE, medunite AARP HEALTH CARE OPTIONS medunite ACORDIA medunite AETNA medunite ALLIANCE AMERI HEALTH, medunite AMERICAN NATIONAL LIFE INS OF TX BANKER'S LIFE,medunite BANKERS FIDELITY, medunite BCBS-medunite BCBS FLORIDA-medunite BENEFIT ADMIN, medunite CAREFIRST-BCBS-MDmedunite CAREFIRST ADMIN, medunite CHAMPVA CIGNA, medunite CONSECO - Medunite CORESOURCE MNTAIRE/BEEBE COVENTRY , medunite DEL PHYS CARE, INC medunite DIAMOND STATE HEALTH PLAN DMERC/ SPECIALITY CLAIMS EYEMED VISION CARE FELLOWSHIP HEALTH RESOURCE FIRST STATE HEALTH , medunite GEMGROUP, LP GEORGETOWN LIONS GHI, medunite GOLDEN RULE GUARANTEE TRUST LIFE , medunit HARRISON HOUSE HOP ADMINISTRATION UNIT - medunite INFORMED INSURANCE ADMIN OF AMERICA INTEGRA ADMIN GROUP MAIL HANDLERS BENEFIT, medunite MAIL HANDLERS, medunite MAMSI, medunite MEDICAID OF DELAWARE MEDICARE RR, medunite MEDICARE, medunite MEGA LIFE & HEALTH INS. CO.medunite MID ATLANTIC ,medunite MILTON LIONS CLUB MUTUAL OF OMAHA-medunite MUTUAL OF OMAHA, medunite NALC HEALTH, medunite NEMOURS ONENET PPO / MAPSI - medunite OPTIMUM CHOICE medunite PEOPLES BENEFIT LIFE, medunite PERDUE HEALTH SMART PHYSICIAN'S MUTUAL -medunite PIONEER LIFE, medunite PRINCIPAL LIFE , medunite PRINCIPAL MUTUAL, medunite PROGRESSIVE AUTO INS RYAN WHITE PROGRAM STANDARD LIFE STARMARK, medunite STATE FARM HEALTH, medunite STERLING LIFE INS TEAMSTER LOCAL 335 TEAMSTERS LOCAL 355 CAREFIRST TEAMSTR 335 H&W (BCBS-MD) THE PRUDENTIAL, medunite TOWNSHIP OF EAST BRUNSWICK ADMINISTRATORS TRICARE,medunite UMWA HEALTH, medunite UNION BANKERS-medunite UNITED AMERICAN-medunite UNITED HEALTHCARE, medunite USAA LIFE, medunite Vision Benefits Of America VOCATIONAL REHAB VSP , medunite WAL-MART, medunite WAUSAU INSURANCE COMPANY WAUSAU, medunite WELLS FARGO TPA, INC
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP- MDCR COMPLETE, medunite AARP HEALTH CARE OPTIONS medunite ACORDIA medunite AETNA medunite ALLIANCE AMERI HEALTH, medunite AMERICAN NATIONAL LIFE INS OF TX BANKER'S LIFE,medunite BANKERS FIDELITY, medunite BCBS-medunite BCBS FLORIDA-medunite BENEFIT ADMIN, medunite CAREFIRST-BCBS-MDmedunite CAREFIRST ADMIN, medunite CHAMPVA CIGNA, medunite CONSECO - Medunite CORESOURCE MNTAIRE/BEEBE COVENTRY , medunite DEL PHYS CARE, INC medunite DIAMOND STATE HEALTH PLAN DMERC/ SPECIALITY CLAIMS EYEMED VISION CARE FELLOWSHIP HEALTH RESOURCE FIRST STATE HEALTH , medunite GEMGROUP, LP GEORGETOWN LIONS GHI, medunite GOLDEN RULE GUARANTEE TRUST LIFE , medunit HARRISON HOUSE HOP ADMINISTRATION UNIT - medunite INFORMED INSURANCE ADMIN OF AMERICA INTEGRA ADMIN GROUP MAIL HANDLERS BENEFIT, medunite MAIL HANDLERS, medunite MAMSI, medunite MEDICAID OF DELAWARE MEDICARE RR, medunite MEDICARE, medunite MEGA LIFE & HEALTH INS. CO.medunite MID ATLANTIC ,medunite MILTON LIONS CLUB MUTUAL OF OMAHA-medunite MUTUAL OF OMAHA, medunite NALC HEALTH, medunite NEMOURS ONENET PPO / MAPSI - medunite OPTIMUM CHOICE medunite PEOPLES BENEFIT LIFE, medunite PERDUE HEALTH SMART PHYSICIAN'S MUTUAL -medunite PIONEER LIFE, medunite PRINCIPAL LIFE , medunite PRINCIPAL MUTUAL, medunite PROGRESSIVE AUTO INS RYAN WHITE PROGRAM STANDARD LIFE STARMARK, medunite STATE FARM HEALTH, medunite STERLING LIFE INS TEAMSTER LOCAL 335 TEAMSTERS LOCAL 355 CAREFIRST TEAMSTR 335 H&W (BCBS-MD) THE PRUDENTIAL, medunite TOWNSHIP OF EAST BRUNSWICK ADMINISTRATORS TRICARE,medunite UMWA HEALTH, medunite UNION BANKERS-medunite UNITED AMERICAN-medunite UNITED HEALTHCARE, medunite USAA LIFE, medunite Vision Benefits Of America VOCATIONAL REHAB VSP , medunite WAL-MART, medunite WAUSAU INSURANCE COMPANY WAUSAU, medunite WELLS FARGO TPA, INC
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None AARP- MDCR COMPLETE, medunite AARP HEALTH CARE OPTIONS medunite ACORDIA medunite AETNA medunite ALLIANCE AMERI HEALTH, medunite AMERICAN NATIONAL LIFE INS OF TX BANKER'S LIFE,medunite BANKERS FIDELITY, medunite BCBS-medunite BCBS FLORIDA-medunite BENEFIT ADMIN, medunite CAREFIRST-BCBS-MDmedunite CAREFIRST ADMIN, medunite CHAMPVA CIGNA, medunite CONSECO - Medunite CORESOURCE MNTAIRE/BEEBE COVENTRY , medunite DEL PHYS CARE, INC medunite DIAMOND STATE HEALTH PLAN DMERC/ SPECIALITY CLAIMS EYEMED VISION CARE FELLOWSHIP HEALTH RESOURCE FIRST STATE HEALTH , medunite GEMGROUP, LP GEORGETOWN LIONS GHI, medunite GOLDEN RULE GUARANTEE TRUST LIFE , medunit HARRISON HOUSE HOP ADMINISTRATION UNIT - medunite INFORMED INSURANCE ADMIN OF AMERICA INTEGRA ADMIN GROUP MAIL HANDLERS BENEFIT, medunite MAIL HANDLERS, medunite MAMSI, medunite MEDICAID OF DELAWARE MEDICARE RR, medunite MEDICARE, medunite MEGA LIFE & HEALTH INS. CO.medunite MID ATLANTIC ,medunite MILTON LIONS CLUB MUTUAL OF OMAHA-medunite MUTUAL OF OMAHA, medunite NALC HEALTH, medunite NEMOURS ONENET PPO / MAPSI - medunite OPTIMUM CHOICE medunite PEOPLES BENEFIT LIFE, medunite PERDUE HEALTH SMART PHYSICIAN'S MUTUAL -medunite PIONEER LIFE, medunite PRINCIPAL LIFE , medunite PRINCIPAL MUTUAL, medunite PROGRESSIVE AUTO INS RYAN WHITE PROGRAM STANDARD LIFE STARMARK, medunite STATE FARM HEALTH, medunite STERLING LIFE INS TEAMSTER LOCAL 335 TEAMSTERS LOCAL 355 CAREFIRST TEAMSTR 335 H&W (BCBS-MD) THE PRUDENTIAL, medunite TOWNSHIP OF EAST BRUNSWICK ADMINISTRATORS TRICARE,medunite UMWA HEALTH, medunite UNION BANKERS-medunite UNITED AMERICAN-medunite UNITED HEALTHCARE, medunite USAA LIFE, medunite Vision Benefits Of America VOCATIONAL REHAB VSP , medunite WAL-MART, medunite WAUSAU INSURANCE COMPANY WAUSAU, medunite WELLS FARGO TPA, INC
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

VISION PLAN

Insurance Information

Insurance Name:	None EYEMED VISION CARE VSP , medunite
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Medical History

Who is your primary care physician?

When was your last visit?

1 month 3 months 6 months 1 year 2 years 3 years > 5 years > 10 years never unsure

What was the reason for your visit?

Please list any over the counter medications you take:

Please list any vitamins you take:

Are you currently taking birth control?

No Yes

Are you currently pregnant or nursing?

No Yes Unsure

Please list your current or previous general health problems:

Please list any previous major injuries, surgeries, or hospitalizations you have had:

Please list any medical problems your family has as well as which member has the problem:

What is your occupation?

Who do you work for?

What is your smoking status?

current everyday smoker current some day smoker smoker former smoker never smoker current status unknown unknown if ever smoked

Do you drink alcohol?

yes no occasionally socially quit

If so, what type?

None Beer Wine Hard Liquor

How long have you drank alcohol for?

1 year 2 years 3 years 5 years 10 years 15 years 20 years > 20 years

Do you use recreational drugs?

yes no quit

If so, what type?

Marijuana Cocaine Acid Mushrooms Bath salts

How long have you used recreational drugs for?

1 year 2 years 3 years 5 years 10 years 15 years 20 years > 20 years

Do you have any sexually transmitted diseases?

None Gonorrhea Syphilis Hepatitis Herpes Chlamydia HIV AIDS

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