WILLIAM GAYA MD PA - Publicforms

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Available Forms

New Patient Registration Form

PATIENT DEMOGRAPHIC INFORMATION

First Name *

Middle Name

Last Name *

as it appears on your insurance card or Medicare card

Date of Birth *

Gender *

Male

Female

as it appears on your medical insurance

Social Security Number

Address *

City *

State *

Zip Code *

Email Address

Phone Number Home

Mobile Number

Work Number

Insurance Information

Primary Insurance Plan

Insurance ID Number

Insurance Group Number

Name of Person on Insurance Card

Secondary Insurance Plan

Insurance ID Number

Insurance Group Number

Name of Person on Insurance Card

Primary Care Physician Name

Preferred Pharmacy

include address or pharmacy number if known in the space provided above

Preferred Pharmacy Phone Number

Social Demographic Data

Marrital status

Single

Married

Life partner

Widow

Divorced

Separated

Employer or Last Job Before Retiring

Emergency Contact Name

Emergency Contact Phone Number

Race

American Indian/Alaskan

Asian

Black/African American

Caucasian/White

Native Hawaiian/Islander

Other

Ethnicity

Hispanic

Non-Hispanic

Unknown

Language

English

Spanish

Other

Medical Information

Reason for this Visit or Consultation

Referring Physician Name

Review of Systems: Check if you have any of the following symptoms for the prior 4 weeks

Symptoms over the last 4 weeks

Please, indicate if you have been diagnosed or treated for any of the following conditions:

Past Medical History

Neurological History

Other symptoms or medical condition not listed above

Medication List

Type in the list of all of your medications in the space provided above

Do you have any allergies? *

Yes

Allergy List

Type in the list of all of your allergies in the space provided above

Surgical History

Brain surgery

Carotid artery surgery

Cervical (neck) spinal surgery

Lumbar or thoracic spinal surgery

None of the above

Family History

Smoking history

Recent Hospital Visits

Check if you had a recent hospital visit with neurological problems or if the hospital visit is related to the new problem pertaining this consultation

* Required field