New Patient Information - Mobile and Poor Vision

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This form collects and stores Personal Health Information. All information is sent and stored in encrypted format. Our technology vendor has signed a HIPPA Business Associate contract to ensure they comply with all HIPPA rules to protect your health information.

Please review our HIPPA Security Policy at Specialty Natural Medicine by clicking here for more information on how your personal health information is protected.

Specialty Natural Medicine requires all new patients to provide new patient information via this online form. If you do not wish to use this form, please contact us immediately to cancel your new patient appointment.

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Do you consent to have your New Patient information securely transmitted and stored with Specialty Natural Medicine and our HIPPA compliant technology vendors?* This field is required.Consent to securely transmit and store personal health information is required for new patients. If you do not consent, please contact us as soon as possible to cancel your new patient appointment.

Yes, I consent to having Specialty Natural Medicine and it's HIPAA compliant vendors securely transmitting and storing my personal health information.

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Date of First Appointment* This field is required.If you have not booked your New Patient Appointment, please visit SpecialtyNaturalMedicine.com/Appointments to request your first visit.

Date

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Name* This field is required.

First Name

Middle Name

Last Name

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Nickname (if applicable)

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Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

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E-mail* This field is required.

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Primary Phone Number for Appointment Reminders, lab results, etc* This field is required.

Area Code

Phone Number

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Patient Date of Birth* This field is required.Please enter Date of Birth. Click on Year at top right corner to quickly change birth year.

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Patient Age* This field is required.

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If Patient is under age 18, who may we contact regarding medical concerns, lab results or other health communication?

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Which race best describes the Patient?* This field is required.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other Race

Decline to Specify

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Which ethnicity best describes the Patient?* This field is required.

Hispanic or Latino

Not Hispanic or Latino

Decline to Specify

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Social Security Number

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Please select which phone numbers that we may use for confidential voice-mail messages.

Mobile Number

Home Number

Work Number

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Mobile Number

Area Code

Phone Number

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Home Number

Area Code

Phone Number

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Work Number

Area Code

Phone Number

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Patient Marital Status* This field is required.

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Patient Occupation

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Emergency Contact Demographics* This field is required.

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Name and Location of Preferred Pharmacy* This field is required.

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Name of Referrer

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I hereby acknowledge that the Responsible Party named on this form is responsible for all expenses incurred by Patient while receiving care at Specialty Natural Medicine. Responsible Party:* This field is required.

Patient

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How would you describe your current menstrual status?* This field is required.

Premenarch (menstruation not started)

Premenopause (before menopause; having regular periods)

Perimenopause / menopause transition (changes in periods, but have not gone 12 months in a row without a period)

Postmenopause (after menopause)

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Age at start of menstrual cycle?* This field is required.

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Average number of days of bleed?* This field is required.

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Average number of days between bleeds?* This field is required.

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Do you bleed/spot between cycles?* This field is required.

Yes

No

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Do you use contraception?* This field is required.

Yes

No

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If yes, please list forms of contraception* This field is required.

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Age at start of menstrual cycle?* This field is required.

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Your age at menopause* This field is required.

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(Menopause Symptoms) - Do you have:* This field is required.

Hot Flashes

Night Sweats

No Menopausal Symptoms

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Primary reason for establishing care?* This field is required.

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Other current health concerns?* This field is required.

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Please list current list of prescription medications and dosage* This field is required.

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List vitamins, minerals, herbs or any other non-prescription medication that you are currently taking with dose* This field is required.

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Please list any severe or life-threatening allergies, including reactions to medicine or materials.* This field is required.List allergies, "no known allergies" if none.

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Have you had any hospitalizations?* This field is required.

Yes

No

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If yes, please provide hospitilization details below* This field is required.

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Have you had any serious illnesses?* This field is required.

Yes

No

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If yes, please provide details and history of serious illness(es) below* This field is required.

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Date of last annual physical and/or gynecological exam* This field is required.

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Date of last blood tests?* This field is required.

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Please list names and ages of your children

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Please check any of the following substances that you currently use* This field is required.

Tobacco

Coffee / Black Tea / Cola

Alcohol

Recreational Drugs

None

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Do you sleep through the night?* This field is required.

Yes

No

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How many hours of sleep do you average per night?* This field is required.

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What exercise do you regularly do and at what frequency?* This field is required.

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Any other personal or family health conditions? Please provide details below.

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Will we be billing insurance for your visit?* This field is required.

Yes

No

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Medical Insurance varies greatly between policies and providers. Please contact your insurance company directly to confirm benefits before your appointment. Specialty Natural Medicine and its representatives can let you know which insurances we are contracted with, but cannot guarantee or offer guidance on specific coverage of individual plans. Please bring in your medical insurance card(s) and your drivers license (or ID) to your first appointment so we can copy for our records.

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Primary Medical Insurance* This field is required.

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Primary Insurance Member ID* This field is required.

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Is the Patient the Subscriber to Primary Medical Insurance* This field is required.Sometimes insurance has a Primary Subscriber who is not the patient. This often occurs with minors/children and spouses when the Primary Subscriber receives benefits from their employer.

Yes

No

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Name and Birthdate of Primary Subscriber* This field is required.

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Will we be billing Secondary Insurance?* This field is required.

Yes

No

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Secondary Medical Insurance* This field is required.

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Secondary Insurance Member ID* This field is required.

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Name and Birth Date of Secondary Subscriber* This field is required.

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Please click submit below or back if you need to edit any information prior to submission.

Note that you MUST click submit for us to receive your information.

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