Patient Registration Form

NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

Question Title

* 1. Patient name

Question Title

* 2. Email

Question Title

* 3. Phone number

Question Title

* 4. Address

Question Title

* 5. Date of Birth

Date

Question Title

* 6. Gender Identity

Man

Woman

Non-binary

Prefer to self-describe (please specify)

Question Title

* 7. Primary Care Physician (PCP)

Question Title

* 8. Primary Care Physician (PCP) phone number

Health History

Question Title

* 9. Are you currently pregnant?

Yes

Question Title

* 10. Do you have any known allergies?

Yes (please specify)

Question Title

* 11. Have you ever had surgery?

Yes (please explain)

Question Title

* 12. Please list all current medications:

Question Title

* 13. Have you experienced any of the following medical conditions?

Acid reflux

Anxiety

Asthma

Cancer

Depression

Diabetes

Eczema

Heart attack

High blood pressure

Migraine headache

Neurological condition

Pulmonary disease

Stroke

Ulcers

Other conditions (please specify)

Question Title

* 14. Reason for patient registration

Question Title

* 15. Preferred Pharmacy

Question Title

* 16. Pharmacy Phone Number

Emergency Contact

Question Title

* 17. Emergency Contact

Question Title

* 18. Relationship

Question Title

* 19. Emergency Contact Phone Number

Insurance Information

Question Title

* 20. Insurance Company

Question Title

* 21. Insurance ID

Question Title

* 22. Policy Holder's Name

Consent to Release Medical Information

Question Title

* 23. Release information to:

Question Title

* 24. Phone number

Question Title

* 25. Fax

Question Title

* 26. I consent to the release of my medical information to the individual named above:

I consent

Question Title

* 27. Signature:

Question Title

* 28. I acknowledge that by entering my name above I am providing a digital signature.

I agree

Question Title

* 29. Please enter the date below.

Date