New Patient Forms

Patient Information

Last Name This field is required

First Name This field is required

Middle Name

Date of Birth This field is required

SSN (Last 4 digits) This field is required

Birth Gender

Male Female

Please select gender

Race This field is required

Ethnic Group This field is required

Language Preferred This field is required

Marital Status

Single Married Divorced Widowed N/A (Minor)

Please select marital status

Address This field is required

City This field is required

State This field is required

Zip Code This field is required

Home Phone

Cell Phone This field is required

Office Phone

Email This field is required

Preferred Contact Method This field is required

Emergency Contact

Name This field is required

Phone This field is required

Relationship This field is required

Insurance Information

I am self-pay / do not have insurance

Check this box to automatically fill insurance fields as not applicable

Insurance Company Name

Enter "Self-pay" if not using insurance

This field is required

Member ID#

Enter "NA" if not applicable

This field is required

Group#

Enter "NA" if not applicable

This field is required

Insurance Phone

Enter "NA" if not applicable

This field is required

Insurance Address

Enter "NA" if not applicable

This field is required

Primary Insured's Name This field is required

Primary Insured's DOB This field is required

Relationship to Patient This field is required

Do you have secondary insurance?

Yes No

Please select an option

If yes, carrier name:

Enter "NA" if no secondary insurance

This field is required

Health History

Previous Physician Name

Enter "None" if not applicable

This field is required

Previous Physician's Address

Enter "NA" if not applicable

This field is required

Present Health Concerns

Enter "None" if not applicable

This field is required

Allergies (list reaction also)

Enter "None" if not applicable

This field is required

Medications currently taking (name, strength, how you take the medication, reason for taking it, and prescribing physician)

Enter "None" if not applicable

This field is required

Past Medical History

Please describe any major medical problems and the date of onset. Example: hospitalizations/surgery & dates, broken bones, chronic conditions, etc.

Past Medical History

Enter "None" if not applicable

This field is required

Social History - Who lives in your home?

Name *	Age *	Relationship *	Highest level of education *

Enter "NA" in all fields of a row if no additional household members

For Adult Patients

Occupation

Enter "NA" if not applicable

This field is required

Spouse's Occupation

Enter "NA" if not applicable

This field is required

Highest level of education

Enter "NA" if not applicable (for pediatric patients)

This field is required

How many children do you have?

Enter "NA" if not applicable

This field is required

Ages

Enter "NA" if not applicable

This field is required

Any use of the following: Caffeine

Never Rarely Moderately Daily N/A

Please select an option and specify type

Alcohol

Never Rarely Moderately Daily N/A

Please select an option and specify type

Tobacco

Never Rarely Moderately Daily N/A

Please select an option and specify type

Drugs

Never Rarely Moderately Daily N/A

Please select an option and specify type

Family History

Please check any box that relates to any family history of the following conditions. If none apply, leave all checkboxes unchecked for that condition.

Condition	Mother	Father	Child	Sibling	Mother's mom	Mother's dad	Father's mom	Father's dad	None/N/A	Other relative (specify)
ANEMIA
ASTHMA
AUTOIMMUNE DISORDER
BLEEDING DISORDERS
CANCERS (SPECIFY)
CONGENITAL ANOMALY/BIRTH DEFECTS
HEART ATTACK/DISEASE
DEPRESSION/MENTAL HEALTH
DIABETES
HIGH CHOLESTEROL
HIGH BLOOD PRESSURE
KIDNEY DISEASE
HISTORY OF STROKE
SUBSTANCE ABUSE
THYROID DISORDER

List any other conditions or comments that you feel are pertinent to your healthcare below:

Enter "None" if not applicable

This field is required

Acknowledgement and Consent

Acknowledgement of Review of Notice of Privacy Practices

I acknowledge that I have received the Notice of Privacy Practices for the office of Gruene Lake Medical, which explains how my medical information will be used and disclosed.

⚠️ Electronic Signature Notice: By typing your full name below, you are creating a legally binding electronic signature that has the same legal effect as a handwritten signature.

Electronic Signature - Type Full Name This field is required

Authorization to Release Information

Authorization to release any information to extended family and/or spouse and children: Please think about anyone who may be calling for information or for billing purposes. Without their name appearing on this form, we will NOT be authorized to release any information. Please list below:

I authorize the following persons to receive private medical or billing information on my behalf regarding my medical care:

Enter "None" if not authorizing anyone

This field is required

⚠️ Electronic Signature Notice: By typing your full name below, you are creating a legally binding electronic signature that has the same legal effect as a handwritten signature.

Electronic Signature - Type Full Name This field is required

Relationship to Patient This field is required

Financial Policy Agreement

I have read and understand the payment policy and agree to abide by its guidelines.

Co-payments, deductibles, co-insurance: All co-payments, deductibles and/or co-insurance must be paid at the time of service. Payment in full is expected at the time of service for all private/self pay patients. If you are insured by a plan with, but don't have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage.

⚠️ Electronic Signature Notice: By typing your full name below, you are creating a legally binding electronic signature that has the same legal effect as a handwritten signature.

Electronic Signature - Type Full Name This field is required

Final Acknowledgement

I certify that all information provided in this form is accurate and complete to the best of my knowledge. I understand that providing false information may result in denial of services. I acknowledge that my typed name above constitutes my legal electronic signature.

You must check this box to submit

Patient Information

Emergency Contact

Insurance Information

Health History

For Pediatric Patients Only: Birth History

Past Medical History

Social History - Who lives in your home?

For Adult Patients

Family History

Acknowledgement and Consent

Acknowledgement of Review of Notice of Privacy Practices

Authorization to Release Information

Financial Policy Agreement

Final Acknowledgement

Thank You!