Medical Admission Form
Medical Admission Form
Please complete this form with accurate details.
Personal Information
Name
Date of Birth
Gender
-
Male
-
Female
-
Phone number
Residential Address
Are you under 18 years old?
Emergency Contact Information
Name
Relationship
Phone number
Address
Medical History
Do you have a history of any chronic illnesses?
If yes, please specify
Are you currently taking any medications?
If yes, please list
Do you have any allergies?
If yes, please specify
Are you pregnant?
Have you been diagnosed with any of the following conditions?
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Hypertension
-
Diabetes
-
Heart Disease
-
Asthma
-
Cancer
Do you smoke?
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Never
-
Rarely
-
Occasionally
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Often
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Always
Do you consume alcohol?
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Never
-
Rarely
-
Occasionally
-
Often
-
Always
Do you use recreational drugs?
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Never
-
Rarely
-
Occasionally
-
Often
-
Always
Insurance Information
Primary Insurance Provider
Policy Number
Are you the primary policyholder?
Primary Policyholder Name
Required Documents
Government-Issued ID
Insurance Card (Front)
Insurance Card (Back)
Terms and Conditions
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Accuracy of Information: By submitting this form, I confirm that all information provided is accurate and up-to-date to the best of my knowledge.
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Privacy Policy: I understand that my personal and medical information will be handled in accordance with HIPAA regulations and will not be shared without my consent.
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Treatment and Billing: I agree to receive medical treatment and acknowledge that I am responsible for any payments not covered by my insurance provider.
Name:
Date:
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