NEUROTEK - Publicforms

Available Forms

New Patient Form

New Patient Registration Form

Please fill out this form completely prior to your New Patient Appointment. It may be helpful to complete at home so you have access to your medication bottles for information. You can also call your Pharmacy or Primary Care Provider (PCP) for an updated medication list if you are not sure. The following information will help us in providing you the best medical care and treatment possible. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

First Name *

Middle Initial

Last Name *

Date of Birth *

SSN *

Sex *

Mailing Address *

City *

State *

Zip Code *

Cell Phone *

Home Phone *

Email Address *

Emergency Contact Name and Phone Number *

Additional Information

Race *

American Indian or Alaska Native

Asian

Black or African American

Hispanic

Native Hawaiian or Pacific Islander

White

Other

Decline

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Decline

Preferred Language

Who is your Primary Care Provider (PCP)? *

Type "None" if not currently established.

Pharmacy of Choice

Please provide pharmacy name, address, and phone number.

Primary Insurance Name

Medical History

Reason for visit *

Height (inches) *

Weight (lbs) *

Please list all MEDICATIONS WITH DOSAGES that you are CURRENTLY taking (including over-the-counter medications and vitamins or supplements bought without a prescription) *

Include the medication name, amount/dose, frequency/time of day taken and how often. (For example: Topamax 25mg twice a day or Ambien 10mg at bedtime).

Please list all medications you have taken IN THE PAST for the medical problem(s) you are addressing at this visit.

(For example: If you have taken Topamax and Imitrex for headaches in the past but are no longer taking, include them here. Or, if you have taken Keppra and Lamictal for seizures in the past, include them here.)

Do you have any allergies to medications, seafood, latex, etc.? Please include here. *

Please check all medical issues that apply to you *

Other

(If Applicable)

Surgical History

Please select/list all surgeries:

Please check all that apply:

Appendix

Tonsils/Adenoids

Hysterectomy

Gallbladder

C-Section(s)

Heart

Other

Social History

Do you smoke cigarettes? *

Do you drink alcohol daily? *

Do you use any illicit drugs? *

Does anyone in your family (living or deceased) have the following:

Family History

Please check all that apply

Other

* Required field