Medical Registration Form
Medical Registration Form
Please fill out the form below to complete your medical registration.
I. Patient Information
Name
Gender
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Male
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Female
Address
Contact Number
Date of Birth
Marital Status
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Single
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Married
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Divorced
-
Widowed
Social Security Number
II. Emergency Contact Information
Name
Relationship to Patient
Phone number
III. Medical History
Primary Care Physician
Phone number
Current Medications
Allergies
Chronic Conditions
Previous Surgeries
Family Medical History
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Heart Disease
-
Diabetes
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High Blood Pressure
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Cancer
-
Stroke
-
Do you smoke?
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Yes
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No
Do you consume alcohol?
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Yes
-
No
Do you exercise regularly?
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Yes
-
No
IV. Authorization and Consent
I hereby authorize the medical provider to administer necessary treatments and procedures as deemed appropriate for my condition. I authorize the release of any medical information necessary to process my insurance claims and facilitate treatment.
Signature
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Name: Date: |
