FHW Primary Care New Patient Request Form

Name of Preferred Provider:

Prefer:

MaleFemaleNo preference

Prefer:

RedlandsFruitaEither Office

Preferred Language:

What are you most looking for from your doctor?

Name:

Date of Birth:

Date

Email:

example@example.com

Social Security Number (this form is encrypted and secure):

Mailing Address:

Mailing Address

Street Address Line 2

City State Zip

Physical Address:

Physical Address

Street Address Line 2

City State Zip

Phone Number:

Phone Type:

Cell PhoneHome Phone

Emergency Contact & Relationship:

Emergency Contact Phone Number:

Insurance:

Member ID Number:

Policy Holder:

Previous or Current Primary Care Physician:

Currently Established Family Members with FHW Primary Care:

If not the patient, who is filling out this application (name, relationship, contact info):

CURRENT AND PAST MEDICAL HISTORY*

CURRENT PRESCRIPTIONS AND OVER THE COUNTER MEDICATIONS*

Do you suffer from chronic pain?

YesNo

Have you taken any prescription medications for pain in the last 12 months?

YesNo

Reason/location of pain:

Please list prescription medications for pain below:*

ALLERGIES / INTOLERANCES TO MEDICATION*

DATES OF LAST PREVENTIVE HEALTH EXAMS

Thorough Health Exam:

Date

Pap Smear:

Date

Mammogram:

Date

Colonoscopy:

Date

HOSPITALIZATIONS (including pregnancies)*

Employer's Name:

Occupation:

Employment Status:

Student Status:

Full-timePart-timeNot a student

Marital Status:

MarriedSingleDivorcedWidowed

Do you use alcohol?

YesNo

Have you ever?

YesNo

How many drinks per week?

Do you use drugs (including marijuana)?

YesNo

Have you ever?

YesNo

What types, and how often?

Do you have a history of alcohol or other substance use that has created problems in your life or for others close to you?

YesNo

If yes, please explain, including any treatment received:

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.

PATIENT'S SIGNATURE

DATE

Date

NEW PATIENT REQUEST FORM

PROVIDER INFORMATION

PERSONAL INFORMATION

SOCIAL HISTORY