NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

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1. Patient name

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3. Phone number

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4. Address

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5. Date of Birth

Date

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6. Gender Identity

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7. Primary Care Physician (PCP)

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8. Primary Care Physician (PCP) phone number

Health History

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9. Are you currently pregnant?

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10. Do you have any known allergies?

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11. Have you ever had surgery?

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12. Please list all current medications:

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13. Have you experienced any of the following medical conditions?

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14. Reason for patient registration

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15. Preferred Pharmacy

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16. Pharmacy Phone Number

Emergency Contact

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17. Emergency Contact

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18. Relationship

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19. Emergency Contact Phone Number

Insurance Information

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20. Insurance Company

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21. Insurance ID

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22. Policy Holder's Name

Consent to Release Medical Information

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23. Release information to:

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24. Phone number

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25. Fax

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26. I consent to the release of my medical information to the individual named above:

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27. Signature:

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28. I acknowledge that by entering my name above I am providing a digital signature.

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29. Please enter the date below.

Date

T