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NEW PATIENT FORM

PLEASE COMPLETE ENTIRE FORM

Patient Information

PATIENT First name

PATIENT Last name

PATIENT Date of birth

Month

Day

Year

Marital Status

SS #

Gender

Prefer Not To Say

PATIENT Phone #

PATIENT Email

PATIENT Address

Country/Region

Address

City

Zip / Postal code

EMERGENCY CONTACT OR INTERPRETER INFORMATION

EMERGENCY CONTACT OR INTERPRETER NAME

PHONE #

RELATIONSHIP TO PATIENT

INTERPRETER'S EMAIL. Enter N/A if this does NOT apply to you.

APPOINTMENT DETAILS

Reason For Visit

New Patient

Immigration/I-693

Pre-Employment

Other

My signature below gives authorization to treat the above named patient.

I authorize the physician to administer such treatment as they deem advisable for my diagnosis and condition. I understand that these services are voluntary and that I have the right to refuse these services.

I authorize Immediate Med to release any information regarding my examination or treatment for the purpose of obtaining workers compensation payments, medical records, certification, or collection expense.

When applicable, I authorize Immediate Med or my insurance company to release any information necessary to process my claims.

I understand that I may be billed for additional laboratory/radiology/office services performed but not charged today.

I agree I will be responsible for any additional fees should my account go to a collection agency.

Use this field to upload your passport, ID, work permit and your vaccination records if you have them available.

Signature

Signature field is empty.

FOR OFFICE USE ONLY- PLEASE LEAVE BLANK

HT: ____________ WT: ___________ BP: __________ T: __________

P:____________ R: ___________ O2: __________

NEW PATIENT FORM

HIPPA OMNIBUS RULE