ADMISSIONS - Paros Practice

PATIENT ADMISSION FORM

Patient's Name

Phone Number

Your Email

Date of Birth of Patient*

Address*

City

State / Province / Region

ZIP / Postal Code

Country

Sex

Male Female Prefer not to say Others

Martial Status

Single Married Divorced Separated Living together Widow/Widower

Do You have Any of the Following Health Issues? (please check those that apply)

High blood pressure Heart disease Lung Issues Hepatitis Fungal infection HIV Other None of the above apply

Do you take any medications? If yes, please list all below and the reason each was prescribed

Do you have any allergies? If yes, please list all below

Have you had any past surgeries or plan to have?

When was the last time you visited a doctor?

Do you drink/consume any of the following items?

Coffee Alcohol Tea Smoke Other

Occupation

In case of an emergency, please list the name, e-mail and phone number of your emergency contact

How did you hear about our practice

Facebook Page Through a Friend Internet Search Others

Government ID (jpg, png, gif, pdf ALLOWED)

Consent

I read and accept the: Terms & Conditions.

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