New Patient Information

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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, enter today's date. You may book your appointment after completing this form at our website: https://www.specialtynaturalmedicine.com/appointments/
Date
Month
Day
Year
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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
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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 Sex* This field is required.
Female
Male
Unknown
Declined to Specify
Other
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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.
Month
Day
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(s) 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
15
Social Security Number
16
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.
Single
Married
Domestic Partner
Divorced
Separated
Widowed
Engaged
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Patient Occupation
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Emergency Contact Demographics* This field is required.
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Name and Street Address of Preferred Pharmacy* This field is required.
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Medication History Consent - Do we have permission to Obtain Medication History?* This field is required.Patient medication history is a list of prescription medicines that our practice providers, or other providers, have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The collected information is stored in the practice electronic medical record system (EHR/EMR) and becomes part of your personal medical record. Medication history is very important in helping healthcare providers treat your symptoms and/or illness properly and in avoiding potentially dangerous drug interactions. It is very important that you and your provider discuss all your medications in order to insure that your recorded medication history is 100% accurate. Some pharmacies do not make drug history information available, and your drug history might not include drugs purchased without using your health insurance. Also over‐the‐counter drugs, supplements, or herbal remedies that patients take on their own may not be included.
YESNO
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How did you hear about us?
Google/Bing Search
Facebook
Insurance Company
Workshop/Lecture
Personal Referral
YouTube Channel
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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. I understand and acknowledge that "No Shows" or Late Cancellations will incur a minimum fee of $180.00 and up to the full billed rate of service. Responsible Party:* This field is required.Late Cancellations are appointments that are cancelled within 24 hours of scheduled appointment start time. No Shows occur when patient is not present and has not contacted the clinic at least 10 minutes after their appointment start time.
Patient
Other
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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
Other
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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
Other
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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 or surgeries?* This field is required.
Yes
No
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If yes, please provide hospitalization and surgery 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.
More than 8 hours of sleep
6 to 8 hours of sleep
Less than 6 hours of sleep
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What exercise do you regularly do and at what frequency?* This field is required.
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Please check each box if the condition applies to you or one of your family members.* This field is required.
Self
Mom
Dad
Sibling
Other
N/A
Alcoholism
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Allergies
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Arthritis
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Cancer
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Diabetes
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Epilepsy
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Heart Disease
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High Blood Pressure
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Mental Illness
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Tuberculosis
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Drug Addiction
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Anemia
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Asthma
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Depression
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Eczema
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Headaches
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Hepatitis
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Kidney Disease
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Stroke
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Crohn's
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Ulcerative Colitis
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COPD
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Alcoholism
Allergies
Arthritis
Cancer
Diabetes
Epilepsy
Heart Disease
High Blood Pressure
Mental Illness
Tuberculosis
Drug Addiction
Anemia
Asthma
Depression
Eczema
Headaches
Hepatitis
Kidney Disease
Stroke
Crohn's
Ulcerative Colitis
COPD
Self
Row 0, Column 0
Mom
Row 0, Column 1
Dad
Row 0, Column 2
Sibling
Row 0, Column 3
Other
Row 0, Column 4
N/A
Row 0, Column 5
Self
Row 1, Column 0
Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Other
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N/A
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Self
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N/A
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Self
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Other
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N/A
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Self
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Mom
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Other
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N/A
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Self
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Other
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N/A
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Self
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Mom
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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Dad
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Sibling
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Other
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N/A
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Self
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Mom
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N/A
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Any other personal or family health conditions? Please provide details below.
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Please note that providing false medical insurance information or failing to disclose if you have medical insurance, including Apple Health, Medicaid or Medicare may result in you having your appointment denied at check-in and patient responsible for the full $200 No Show fee. Please disclose all medical insurance even if you plan to pay cash for your visit.* This field is required.
I understand that I need to disclose any medical insurance I have. If I present insurance information at check-in that was not disclosed on this form, my appointment may be cancelled and I will need to pay the $200 No Show fee.
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Do you have medical insurance?* This field is required.We are contracted with the following insurance companies: Blue Cross/Blue Shield, Regence, Premera, Lifewise, First Choice, Uniform and HMA. All other insurance is out of network and will be based on a "cash" basis with payment in full due at time of service. More details at https://www.specialtynaturalmedicine.com/about_us/contact-us/billing-questions/
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.
61
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
62
Name and Birthdate of Primary Subscriber* This field is required.
63
Will we be billing Secondary Insurance?* This field is required.
Yes
No
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Secondary Medical Insurance* This field is required.
65
Secondary Insurance Member ID* This field is required.
66
Name and Birth Date of Secondary Subscriber* This field is required.
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Please verify that you are human* This field is required.
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