NEW PATIENT FORM

Welcome to our office!

Full Name: *

Sex: *FemaleMale

Birthdate: *

Month

Day

Year

Patient SSN: *0 / 9

Marital Status:

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Home Phone:

Cell: *

Work:

Email Address: *

Occupation: *

Emergency Contact Name: *

Emergency Contact Phone: *

Relation: *

Preferred Method for Appointment Reminders:

Insurance and Responsible Party Information:

Primary Insurance Name: *

Subscriber Name: *

Subscriber Date of Birth: *

Month

Day

Year

Secondary Insurance Name: *

Subscriber Name: *

Subscriber Date of Birth: *

Month

Day

Year

If the patient is a minor, who will be responsible for payment:

Full Name:

Relationship to Patient:

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Is this injury related to a workers' compensation claim or auto accident?

Contact Phone Number:

Name of Insurance Company:

Date of Injury:

Month

Day

Year

Claim #:

Is this claim open?

If yes, please upload the Open Claim Letter:

No file chosen

Your Pharmacy Name:

Pharmacy Phone Number:

Cross Roads or Address of Pharmacy:

Name of your Primary Care Physician:

Phone Number:

Fax Number:

Primary Care Address:

Hospital Affiliation (If Known):

Are you diabetic?: *YesNo

If yes, what type?:Type 1Type 2

Have you been vaccinated against influenza? *YesNo

Date of Vaccination:

Have you been vaccinated against pneumonia? *YesNo

Date of Vaccination:

If yes, the name of your treating physician:

Last A1C:

Last Blood Sugar:

Alcohol Use: *NeverSocial Alcohol UseHeavy Alcohol UsePrevious Alcohol Use

Are you allergic to latex products? *YesNo

Current Medications

Non-prescription medications you take routinely (ex. vitamins, supplements):

Please list any surgical procedures you have had in the past:

Overall Health: *GoodFairPoor

Height *

Weight *

Constitutional: *FeverWeight LossLethargyNonePlease check any that apply or select "None."

Endocrine: *Night SweatsThyroid DiseaseDiabetesNonePlease check any that apply or select "None."

Warren

26440 Hoover Rd.

Warren, MI 48089

Monday: 9:00 am-5:00 pm

Tuesday: 8:00 am-4:00 pm

Wednesday: 9:00 am-5:00 pm

Thursday: 9:00 am-5:00 pm

Friday: 8:00 am-4:00 pm

Saturday & Sunday: Closed

(586) 756-3338

St. Clair Shores

27593 Harper Ave.

St. Clair Shores, MI 48081

Monday: 9:00 am-5:00 pm

Tuesday: 9:00 am-5:00 pm

Wednesday: 9:00 am-5:00 pm

Thursday: 9:00 am-5:00 pm

Friday: 8:00 am-4:00 pm

Saturday & Sunday: Closed

(586) 779-6140

Macomb

46591 Romeo Plank Rd #104

Macomb, MI 48044

Monday: 9:00 am-5:00 pm

Tuesday: 8:00 am-5:00 pm

Wednesday: 9:00 am-4:00 pm

Thursday: 9:00 am-5:00 pm

Friday: 8:00 am-5:00 pm

Saturday & Sunday: Closed

NEW PATIENT FORM

Insurance and Responsible Party Information:

If the patient is a minor, who will be responsible for payment:

Warren

(586) 756-3338

St. Clair Shores

(586) 779-6140

Macomb

(586) 416-3668