Please fill out registration information below (Step 1 of 2)

Employer Information
Employer		Phone #
Address
City		State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY          Zip
Occupation

Information and Insurance Benefits
I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original.
Date		Signature
I hereby authorize Dr.___________________ to apply for benefits on my behalf for covered Services rendered by him/her, or by his/her order. I request that payment from my insurance company be made directly to Dr.___________________ (or to the party who accepts assignment). I certify that the information I have reported with regard to my insurance coverage to correct. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by either my insurance company or me at any time in writing.
Date		Signature
(Patient, parent, or guardian)
Name		SS#

General Medical Information
Describe the current medical problem/reason for today’s visit
Present Medications
Allergies to Medications
Allergies (e.g., itchiness or hives) to special brands of soap/laundry detergent
Other physicians currently treating you
Previous or other medical problems
List any previous surgeries or hospitalizations (include number of miscarriages and live births)
Females only: Are you pregnant, planning a pregnancy or nursing a child?	N/A Yes No

Do you smoke? Yes No	No. of Yrs	How Much?	Interested in Stopping? Yes No
Do you regularly drink alcohol?		How many ounces/ beers per day?
Do you regularly drink coffee?		How many cups per day?
Are you under a lot of pressure at work?		Please Describe