• 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.

  • Patient Demographics

  • Date of First Appointment*
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    2 digit month, 2 digit day, 4 digit year
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  • Patient Sex*

  • If Patient is under age 18, who may we contact regarding medical concerns, lab results or other health communication?
  • Which race best describes the Patient?*
  • Which ethnicity best describes the Patient?*
  • Please select which phone numbers that we may use for confidential voice-mail messages.
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  • Emergency Contact Demographics*

  • History and Review of Systems

  • Please check any of the following substances that you currently use*
  • Please check each box if the condition applies to you or one of your family members.*
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  • Will we be billing insurance for your visit?*

  • 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.

  • Is the Patient the Subscriber to Primary Medical Insurance*
  • Will we be billing Secondary Insurance?*

  • 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.

  • Should be Empty: