Lifestyle Docs - Publicforms

Available Forms

I. New Patient Registration Form, Required II Uninsured New Patient Registration Form III. Patient Medical History, Required IV. Request an Appointment IV. Review of Systems IX. Spanish Patient Medical History, Required V. Lifestyle History, Optional V. Nutrition & Dietary Habits, Optional VI. Detailed Autoimmune Disease History, Optional VI. Detailed Diabetes History, Optional VI. Detailed Digestive Health History, Optional VI. Detailed Hypertension History Optional VI. Detailed Weight History, Optional VII. Spanish New Patient Registration Form VII. Spanish Uninsured New Patient Registration Form

II Uninsured New Patient Registration Form

Name *

Please, enter your first name followed by last name

Sex *

Male

Female

Date of Birth *

Social Security Number *

Pharmacy & Phone # *

Please, give the name of your Preferred pharmacy and its phone number

Marital Status

Race/ethnicity

Contact Information

Cell Phone *

Please, enter your cell phone

Best way of reaching you

If this cell phone is the best way to reach you, please check this box. If not, provide an alternate phone

Alternate Phone

Email *

Please, provide your email <br/>

Confirm email *

Please, re-enter your email

Address *

Please, enter your complete address including your street address, city, state and zip code.

Business Phone

Emergency Contact *

Individual to contact, in case of emergency

Relationship

Indicate your relationship to emergency contact

Emergency Contact Phone *

Best phone to reach the Emergency Contact

Group Visits/Sessions

I would like to participate in group visits, group support sessions with the medical personnel at Embee Lifestyle Docs

Yes

Unsure

I understand that this will divulge my medical condition and other personal medical information to other group member(s). I agree to keep all information that is shared in the group by other member(s) confidential and to not discuss such information outside of the group. I understand that I don?t have to share any personal information with the group or health care providers unless I choose to do so.

Signature *

Only if you selected yes on the above field then typing your name in this field will be equivalent to signing your name on a paper document and will indicate your consent to participate in group visits/sessions.

Financial Policy and other General Policies

I hereby acknowledge that I have reviewed and agree with the Financial Policy and other General Policies of this practice available on the website at lifestyledocs.com. I authorize Embee Lifestyle Docs, PLLC to charge my credit card for the various services as outlined on the Financial Policy.

Signature *

Typing your name in this field will be equivalent to signing your name on a paper document. Please, sign in this field only after reviewing the Financial Policy and other General Policies document.

Privacy Policy

I hereby acknowledge that the Privacy Policy for Embee Lifestyle Docs, PLLC has been made available to me for review. I have reviewed the Privacy Policy for this practice on the website for lifestyle docs. I am aware that the Privacy Policy for this practice may change from time to time and that the current copy of the Privacy Policy is always available on the lifestyledocs.com website.

Signature *

Typing your name in this field will be equivalent to signing your name on a paper document. By signing my name in the above box, I acknowledge that I have reviewed the Privacy Policy for Embee Lifestyle Docs, PLLC.

* Required field