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New Patient

New patient registration

Please complete this form before your first visit. All information is kept confidential and used solely to provide you with the best care.

Personal Information

Medications

Are you currently taking any medications? / ¿Está tomando algún medicamento actualmente? *

Lifestyle

Do you drink alcohol? / ¿Bebes alcohol? *

Do you smoke cigarettes? / ¿Fumas cigarrillos? *

Do you use any recreational drugs? / ¿Consumes alguna droga recreativa? *

Medical Conditions

Do you have any pre-existing medical conditions? / ¿Tiene alguna condición médica preexistente? *

Diagnosed with Diabetes? / ¿Le han diagnosticado diabetes? *

Diagnosed with a Thyroid condition? / ¿Enfermedad de la tiroides? *

Diagnosed with pancreatitis? / ¿Pancreatitis? *

Is there a history of serious illness in your family? / ¿Antecedentes de enfermedades graves en su familia? *

Reproductive Health

Are you currently pregnant? / ¿Estás embarazada actualmente? *

Are you trying to conceive? / ¿Tratando de concebir? *

Are you currently breastfeeding? / ¿Amamantando actualmente? *

Lab Work & Vitals

COVID-19 Vaccination Status

What is your COVID-19 vaccination status? *

Visit Information

Are you currently under Physician Supervision? / ¿Está bajo supervisión médica? *

You are here for / ¿Para qué estás aquí? *

How did you hear about us? / ¿Cómo te enteraste de nosotros? *

Signature / Firma

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