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New Patient Registration Form: Adult

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Demographics


Demographics

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Gender:
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Marital Status:
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Preferred method of contact?
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Emergency Contact Information


Emergency Contact Information

IN CASE OF EMERGENCY, who will be notified?
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Spouse's Information


Spouse's Information

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How did you hear about Northern Illinois Foot & Ankle Specialists?
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Insurance & Pharmacy Information


Insurance & Pharmacy Information

PLEASE CONTACT YOUR INSURANCE COMPANY PRIOR TO YOUR APPOINTMENT TO VERIFY YOUR BENEFITS
Will you be using insurance?
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Patient History


Patient History

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Preferred Language
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Ethnicity - Hispanic or Latino?
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Race
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Smoking/Drinking History
Do you smoke?
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Do you drink alcohol?
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ALLERGIES: MEDICATION/ENVIRONMENTAL
Activity Level
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Past Medical History


Past Medical History

If female, is there a chance you are pregnant?
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Family History of Medical Problems


Family History of Medical Problems


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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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