New Patient Enrollment Form

New Patient Registration

Please fill in the form below
Requesting New Appointment with:

Dr. George Thomas KeithDr. Minh TranDr. Ajay JainDr. Kiran D. Nair
Name*

First NameMiddle NameLast Name
E-mail
Sex
Date of Birth*

MonthDayYear
Race
Ethnicity
Driver's License
Please enter your driver's license number
State
Please enter the state for your Driver's license
Home Number:

Area CodePhone Number
Cell Number:

Area CodePhone Number
Current Employer
Please name your current employer, if any
Work Number:

Area CodePhone Number
Marital Status
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Insurance Information
Insurance

Insurance Company Name

Insured person name if not self

Policy NumberGroup Number

Phone Number
Second Insurance - Fill if Dual Coverage

Insurance Company Name

Insured person name if not self

Policy NumberGroup Number

Phone Number
Referring Physician
Please list your referring physician
Primary Care Physician
Please list your PCP if different
Major illnesses
Please list illnesses that you currently have
Current Medications
Taking any medications, currently?

YesNo
Current Medications
If yes, please list current medications here with doses and frequency
Preferred Pharmacy
Name:
Please enter the name of your pharmacy
Address:

Street Address of Pharmacy

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number

Area CodePhone Number
Pharmacy Fax Number

Area CodePhone Number
Mail-in Pharmacy
Name:
Please enter the name of your pharmacy
Social History
Smoker or tobacco use
Please indicate smoking status - Please reply yes if you vape or chew tobacco
Packs per day
Please indicate how many packs you smoke or smoked per day
Years Smoked
Please indicate how many years in total you smoked for
Year Quit
Please indicate the year you completely quit smoking
Alcohol Consumption
Please indicate how much of any type of alcoholic drinks you consume, and how often you do
Drug Abuse
Please indicate if you have currently or previously consumed other unprescribed drugs including THC vapingor Marijuana use
Chronic Chemical exposure history
Please indicate if you have had any chronic exposure to chemicals that concern you - please indicate the circumstances and duration of exposure
Please list your medication allergies
Please medications you are allergic to and the effect the medication has on you
Please list any pertinent family medical conditions
Please list medical conditions in your first degree relatives - parents, siblings, children
Please check to Acknowledge

I have read and acknowledged the cancellation/No-show policy
Signature*

Clear
Please sign using your cursor
Date of Signature

MonthDayYear
Date
Should be Empty:

New Patient Registration