Dr. Robert G. Parker New Patient Registration

First Name *

Last Name *

Date of Birth *

Sex *

Male

Female

Address *

City *

State *

Postal code *

Phone *

May we leave a message? *

Yes

No

Email *

Primary Language *

English

Spanish

Emergency Contact Name *

Emergency Contact Phone *

Primary Care Doctor *

Pharmacy *

Pharmacy Phone *

If there is another person that you would like for us to share your medical information with, please list them.

Name

DOB

Phone

Primary Insurance

Member ID

Secondary Insurance

Member ID

Do you have any medication that you are currently taking? *

Yes, please list below

No, I am not currently taking any medication

Medication

Medication, Dosage
Medication, Dosage
Medication, Dosage
Medication, Dosage
Medication, Dosage
Medication, Dosage
Medication, Dosage
Medication, Dosage

Do you have allergies other than seasonal? *

Yes, please list below

No Known Allergies

Allergies

Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction

Check this box if there is no allergies to be listed.

No Allergies or Allergy Medication

Smoking Status *

Current Smoker

Former Smoker

Never Smoked

Have you had any past surgeries? *

Yes, please list below

No past surgeries

Past Surgeries

Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date

Diabetes *

N/A

Mother

Father

Cancer *

N/A

Mother

Father

Heart Disease *

N/A

Mother

Father

High Blood Pressure *

N/A

Mother

Father

Stroke *

N/A

Mother

Father

Coronary Artery Disease *

N/A

Mother

Father

Thyroid Disorder *

N/A

Mother

Father

Rheumatoid Arthritis *

N/A

Mother

Father

Current Problem *

When did the problem start? *

How did the problem start? *

Suddenly

Gradually

Traumatic

Slowly

Since the problem began, has it: *

Stayed the same

Become worse

Got better than worse

Improved

How would you rate your pain on a scale from 0 to 10?

To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. I agree and understand that by typing my name, all electronic signatures are the legal equivalent of my manual/handwritten signature. *

Date *

"I hereby authorize the physicians or designated staff to provide the necessary treatment to me. I also authorize the release of any medical information necessary to process claims and verify coverage. I understand that I am responsible for any deductibles, copays, and coinsurance not covered by my insurance policy. I acknowledge that I have read and understand the office and financial policies." I agree and understand that by typing my name, all electronic signatures are the legal equivalent of my manual/handwritten signature. *

Today's Date *

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