New Patient Paperwork & Medication List
Name
*
First Name
Middle Initial
Last Name
Preferred Name
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Subscriber
Please list the insurance subscriber (if patient is not subscriber)
Subscriber Name
*
First Name
Middle Initial
Last Name
Subscriber Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Patient
Primary Insurance:
*
Policy Number
*
Group#:
*
Secondary Insurance:
Policy Number
Group#:
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IMMUNIZATION RECORD
*
Tetanus
Flu Vaccine
Hepatitis Vaccine
Pneumonia Vaccine
Covid Vaccine
N/A
Other
Date of the last Tetanus vaccine and dose taken.
*
Date of the last Hepatitis Vaccine and dose taken.
*
Date of the last Pneumonia Vaccine and dose taken.
*
Date of the last Flu Vaccine and dose taken.
*
Date of the last COVID-19 Vaccine and dose taken.
*
List other vaccines and year and dose taken.
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING - Prescription and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin)
*
Rows
DATE/STARTED
NAME OF MEDICATION
DOSE/HOW MANY PER DAY
STOPPED
Notes: Reason for taking/Doctor
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2
3
4
5
6
7
8
9
10
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12
13
14
15
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