1540 Centennial Ct #300, Casper, WY 82601 • 307.337.4981

New Patient Form

Patient's Legal Name

First Name

Last Name

Email Address

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Age

SSN

Marital Status

Gender

Are you currently taking any blood thinners?

Are you diabetic?

Please list ALL allergies

Which Pharmacy do you want us to send prescriptions to?

Please list ALL medications, dosage, and how often you take it

Name / Dose / How Often do you take?

Referring Doctor, or Primary Care Doctor if not referred

Employer

If retired, please put retired/date of retirement. If student, please put name of school/part time or full time.

Employer Phone Number

(###)

###

####

Spouse Name

First Name

Last Name

Spouse Age

Spouse Date of Birth

YYYY

Spouse Phone Number

(###)

###

####

Spouse SSN

Spouse Employer

If retired, please put retired/date of retirement.

Spouse Employer Phone Number

(###)

###

####

Responsible Party

If other than patient, please fill in below

Name and Relationship

SSN

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone 4

(###)

###

####

Employer

Emergency Contact Information

Name of Friend or Relative

First Name

Last Name

Relationship

Address 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone 5

(###)

###

####

Please note that we now require a copy of your Medicare, Medicaid and/or Insurance Card to verify the mailing address, phone number, and the spelling of your name as shown o each individual card. We cannot file insurance claims for you without the birthdate and social security number of the policy holder.

We are also requiring a copy of your driver’s license or other picture ID that includes your signature. This is to be able to verify your identity in the event of requests for release of Private Health Care information.

We appreciate your help and understanding of these requests.