New Patient Form
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3New Patient Form
Section 1
Name____________________________________________________________________________________
Address __________________________________________________________________________________
City __________________________ST ________Zip______________
Apt #__________________________
Day Phone (____)____________________ Cell Phone (____)________________
Member ID# _____________________________________________
Group#________________________
Email Address____________________________________________
Birth Date ______/_______/_________
Male
Female
Doctor’s name______________________________________________ Phone # (____)________________
Doctor’s name______________________________________________ Phone # (____)________________
Payment options:
Check
Money order
Payment enclosed
Credit Card
Section 2
Visa
American Express
Discover
MasterCard
Card #
Exp date
Sec code
Cardholder_____________________________________________________________________
Sign ___________________________________________________________________________
I authorize LSC to use card for all scripts in future. Number of prescriptions with order________
Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects.
To best serve you, we need to know if you have any medication allergies or medical conditions. We also need to know what
non-prescription medications you take regularly.
Patient Medication Allergies
Section 3
Fill in the oval completely if the patient has had an allergy or serious reaction to any of these medications:
Aspirin and salicylates (for example: ZORprin
, Trilisate
)
®
®
Codeine (for example: Tylenol
#3)
®
Erythromycin, Biaxin
, Zithromax
®
®
Nonsteroidal anti-inflammatory drugs (NSAIDS) (for example: ibuprofen, Advil
, Motrin
)
®
®
Penicillins/cephalosporins (for example: Amoxil
, amoxicillin, ampicillin, Keflex
, cephalexin)
®
®
Sulfa drugs (for example: Septra
, Bactrim
, TMP/SMX)
®
®
Tetracycline antibiotics
If the patient has an allergy to a medication that is not listed above, print the name of that medication in
the space below. Example: morphine
Other:_____________________________________________________________________________
Other:_____________________________________________________________________________
(please continue on next page)
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Parent category: Medical