New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State/ZipCode
WV
KY
OH
PA
TN
VA
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Unknown
Single
Married
Separated
Divorced
Widowed
Child
Employer/School Name
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address
City
State
ZipCode
WV
KY
OH
PA
TN
VA
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
BCBS FREEDOM BLUE CLAIMS
CHIPS
FAYETTE CONTINUOUS CARE
FCBOE
HIDDEN VALLEY-THE SUMMIT
HIDDEN VALLEY NURSING HOME
HIGHMARK BCBS
HILLTOP NURSING HOME
HUMANA
INFORMED
MEDICARE
New Insurance
NEW RIVER HEALTH
PEIA (HEALTHSMART BENEFIT SOLUTIONS)
SelfPay
UFCW
UMWA 1950 AND 1974
UMWA 1993
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:
SSN:
Employer/School:
Secondary
Insurance Information
Insurance Name:
None
BCBS FREEDOM BLUE CLAIMS
CHIPS
FAYETTE CONTINUOUS CARE
FCBOE
HIDDEN VALLEY-THE SUMMIT
HIDDEN VALLEY NURSING HOME
HIGHMARK BCBS
HILLTOP NURSING HOME
HUMANA
INFORMED
MEDICARE
New Insurance
NEW RIVER HEALTH
PEIA (HEALTHSMART BENEFIT SOLUTIONS)
SelfPay
UFCW
UMWA 1950 AND 1974
UMWA 1993
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:
SSN:
Employer/School:
Tertiary
Insurance Information
Insurance Name:
None
BCBS FREEDOM BLUE CLAIMS
CHIPS
FAYETTE CONTINUOUS CARE
FCBOE
HIDDEN VALLEY-THE SUMMIT
HIDDEN VALLEY NURSING HOME
HIGHMARK BCBS
HILLTOP NURSING HOME
HUMANA
INFORMED
MEDICARE
New Insurance
NEW RIVER HEALTH
PEIA (HEALTHSMART BENEFIT SOLUTIONS)
SelfPay
UFCW
UMWA 1950 AND 1974
UMWA 1993
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:
SSN:
Employer/School:
Medical History
PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid
Injuries, Surgeries, Hospitalization
Please list all your medications:
Please list all the over-the-counter medications you take:
Vitamins:
Please list all eye drops:
Please list all Drug Allergies:
Primary Care Physcian:
Doesn't Remember
Doesn't Have One
None
Keaveny
Newell
Petersen, Bruce
Petersen, Millie
White
Other
FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other
Hobbies:
Tobacco:
No
Yes
Type:
None
Chewing Tobacco
cigarettes
How Long:
Alcohol:
No
Yes
Occasionally
Socially
Illegal Drugs:
No
Yes
Type:
How Long:
Pregnant Or Nursing:
No
Yes
Unsure
Submit Data
After Completing All Forms Submit Data on Final Tab