FHW Primary Care New Patient Request Form

  • NEW PATIENT REQUEST FORM

  • Please complete this questionnaire in full to help us understand your healthcare needs so we can work towards matching you with a provider in our clinic. FHW and D51 employees are automatically accepted, but a completed form is still required. If you have no information to provide, write ” or “N/A.” Incomplete questionnaires will not be accepted.

  • PROVIDER INFORMATION

  • Prefer:
  • Prefer:

  • PERSONAL INFORMATION

  • Date of Birth:
     / /
  • Format: (000) 000-0000.
  • Phone Type:
  • Format: (000) 000-0000.
  • Do you suffer from chronic pain?
  • Have you taken any prescription medications for pain in the last 12 months?

  • DATES OF LAST PREVENTIVE HEALTH EXAMS

  • Thorough Health Exam:
     - -
  • Pap Smear:
     - -
  • Mammogram:
     - -
  • Colonoscopy:
     - -

  • SOCIAL HISTORY

  • Employment Status:
  • Student Status:
  • Marital Status:
  • Do you use alcohol?
  • Have you ever?
  • Do you use drugs (including marijuana)?
  • Have you ever?
  • Do you have a history of alcohol or other substance use that has created problems in your life or for others close to you?

  • ACKNOWLEDGMENT

    By signing this Acknowledgment, I agree that the above information is true and correct. I authorize FHW Primary Care to leave a voicemail on the phone number(s) provided unless otherwise noted. I understand that, should there be any missing information, FHW Primary Care reserves the right to refuse service and that a $40 no-show fee will be charged for all no-show appointments. I acknowledge that FHW Primary Care participates with the Colorado Prescription Drug Monitoring Program and Quality Health Network, which are centralized databases for healthcare professionals, and I authorize my provider to review my medical history. I further understand that I am responsible for my account balance and that FHW Primary Care will bill my insurance, and if there is a deductible or co-pay, it is due at the time of service.

  • Clear
  • DATE
     / /
  • Should be Empty: