Care Provider Application Form

A multi-page new-patient application that a healthcare practice uses to collect contact and emergency information, payment preference, health history, and habits, ending with a signed consent from the patient or a parent/guardian.

Use this template

Page 1

Full Name

Nombre

Apellido

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Birth Date

Gender

Employer

E-mail

Occupation

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Emergency Contact

Emergency Contact Phone Number

Primary Care Provider

Primary Care Provider Phone Number

How were you referred to our office?

Page 2

How I plan to pay for treatment:

Insurance Self-pay/Cash Credit Card Payment Plan Gift card/Promotional

Gift card/promotional number

Page 3

Are you experiencing any of the following? (Please check all that apply)

Headaches Joint Pain Fatigue Difficulty Sleeping Anxiety or Stress None of the above

List any major illnesses or hospitalizations:

What medications or drugs are you taking?

Have you been treated for any health conditions in the last year?

Yes No

List any other health problems, no matter how insignificant they may be:

Page 4

Purpose of this appointment:

Have you ever had the same or a similar problem?

Yes No

If yes, please describe:

Page 5

Do you do any of the following? (Please check all that apply)

Smoke Drink alcohol regularly Exercise regularly Use recreational drugs None of the above

If you checked any of the options above, please detail below:

What are your hobbies?

Page 6

Do any of your family members suffer from these? (Please check all that apply)

Page 7

Consent to Treatment

I understand that the information provided above is accurate and complete to the best of my knowledge.

I authorize the care provider to review my health information for the purpose of this application.

I understand that payment is due at the time of service unless other arrangements have been made.

By signing below, I acknowledge and agree to the above terms.

Page 8

Patient Signature Section

Please sign and date below to confirm the accuracy of this application.

Patient's Signature

Date

If the patient is a minor, a parent or legal guardian must also sign below.

Parent/Guardian Authorization

Parent/Guardian Signature