MAKE AN APPOINTMENT
About Us
Locations
Providers
Accepted Insurance
Services
Our Services
Botox
Mobile Healthcare Unit
Baseline Health
Patient Portal
Contact
About Us
Locations
Providers
Accepted Insurance
Services
Our Services
Botox
Mobile Healthcare Unit
Baseline Health
Patient Portal
Contact
Today’s Date:
First Name
Last Name
Date of Birth:
SS#:
Address:
City:
State, Zip:
Home Phone:
Work:
Cell:
Email Address:
Sex:
Male
Female
Marital Status:
Single
Married
Divorced
Separated
Widowed
Are you currently working?
Yes
No
Retired?
Yes
No
Last date worked:
Employer:
Employer’s Phone #:
Employer’s Address:
City:
State, Zip:
Worker's Comp Insurance
No Fault Insurance
Private Medical Insurance
Self Pay
Primary Insurance Carrier:
Phone:
Policy#:
Group#:
Insurance Company’s Address:
Patient Relationship to Insured:
Self
Spouse
Child
Other
Insured SS#:
Secondary Insurance Carrier:
Phone:
Policy#:
Group#:
Insurance Company’s Address:
Patient Relationship to Insured:
Self
Spouse
Child
Other
First Name:
Last Name:
DOB:
List ALL MEDICATIONS you take, including over the counter (OTC) medications and vitamins. Include specific doses and when taken. If you do not know, please call your pharmacist to confirm.
Medical Conditions (Check All That Apply)
ADHD
COPD/ Emphysema
High Cholesterol
Rheumatoid Arthritis
Alcoholism
Dementia
HIV
Seizure Disorder
Allergies, Seasonal
Depression
Hepatitis
Sleep Apnea
Anemia
Diabetes: 1 or 2
Irritable Bowel Syndrome
Stroke
Anxiety
Diverticulitis
Lupus
Thyroid Disorder
Arrhythmia (irregular heartbeat)
DVT (Blood Clot)
Liver Disease
Ulcerative Colitis
Arthritis
GERD (Acid Reflux)
Macular Degeneration
Gout
Asthma
Glaucoma
Neuropathy
Crohn’s Disease
Bipolar
Heart Disease
Osteopenia/Osteoporosis
Chest pains
Bladder Problems
Heart Attack (MI)
Parkinson’s Disease
Pulmonary Embolism
Bleeding Problems
Hiatal Hernia
Peripheral Vascular Disease
Palpitations
High Blood Pressure
Peptic Ulcer
Cancer:
Psoriasis
Headaches
Kidney Stones
Kidney Disease
Tuberculosis
Other medical problems not listed above:
Surgical History: Please list all prior surgeries and approximate dates performed. Any Major Illnesses:
Allergies to Medicine:
Any Other Type of Allergies:
Please check one that applies:
Smoker
Non-Smoker
EMERGENCY CONTACT
Relationship to Patient:
Spouse
Child
Other
ADDRESS
CITY
STATE
ZIP
CELL
WORK
NAME
ADDRESS
CITY
STATE
ZIP
TELEPHONE
Signature
❌
Submit
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