Patient Medical History and Insurance Information Forms

If you are a new patient, you will be expected to fill out a patient information form with your address, phone, and insurance information prior to your appointment. Even if you download the form and fill out all the insurance information, please be sure to bring your insurance card with you to your appointment. You will also fill out a medical history form. Filling out both these forms can take a little time, so we routinely ask you to come in 20 minutes prior to your first appointment to do the paperwork and read the 7 page HIPAA privacy policy, which you must now read according to the new Health Information Portability Accountability Act (HIPAA). If you are able to do this at home, it can be a real timesaver.

To download the forms, just click on the links below. You'll need Adobe Acrobat viewer to open and print the forms on your computer. You probably have this on your computer already, but if not, more information on Acrobat Reader and where you can download it can be found here.

Please download and print the following TWO forms (marked with *). Don't forget to bring them with you for your appointment!

* Patient/Insurance Information form (pdf)

* Medical History form (pdf)

You must review our privacy policy and then sign off in the patient/Insurance Information form above that you read or received a copy of the privacy policy .

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The versions of the forms below are "electronic forms" with editable fields which allow you to type your information while in Adobe Acrobat Reader. You can then print the form neatly on your printer. Note that this version of the form is slightly different than above -- with all the added form fields and checkboxes, keeping >100 new objects on the page created forms which were >1MB in size EACH! I reduced the number of fields and checkboxes to keep the size of the file small. If you need to do more than one form for your family, duplicate it and fill out each separately. If you click the "reset button" at the bottom of the form, it will ERASE everything you typed.

patient/insurance info electronic form (pdf)

medical history electronic form (pdf)

You must review our privacy policy and then sign off in the patient/Insurance Information form above that you read or received a copy of the privacy policy .

Note: the medical history electronic form has a section which asks about a whole bunch of medical symptoms you might be having. I couldn't make checkboxes for all these symptoms because it generated too much overhead and caused this single page form to increase to over 1MB in size. This was not acceptable, if we are to have pity on those still using modem connections. YOU WILL NEED TO FILL OUT THESE CHECKBOXES BY HAND, but everything else on the form can be filled out from the keyboard!