New patient forms

Here are some examples of new patient forms that a healthcare provider might use:

Patient Information Form

• Patient name: _____
• Date of birth: _____
• Address: _____
• Phone number: _____
• Email address: _____
• Insurance information: _____

Medical History Form

• List of current medications: _____
• List of allergies: _____
• Previous illnesses or surgeries: _____
• Family medical history: _____
• Any chronic medical conditions: _____

Social History Form

• Marital status: _____
• Occupation: _____
• Education: _____
• Smoking status: _____
• Drinking status: _____
• Any substance abuse: _____

Insurance and Billing Information Form

• Insurance provider: _____
• Insurance policy number: _____
• Primary care physician: _____
• Referring physician: _____
• Any out-of-pocket costs: _____

Authorization for Release of Information Form

• I authorize the release of my medical information to the following individuals or organizations: _____
• I understand that this information may be used for treatment, payment, or healthcare operations: _____

Consent for Treatment Form

• I consent to receive treatment from [provider name] for the following condition(s): _____
• I understand that treatment may involve the use of medications, procedures, or other interventions: _____

HIPAA Notice of Privacy Practices Form

• I understand that my protected health information (PHI) will be used and disclosed in accordance with the Health Insurance Portability and Accountability Act (HIPAA): _____
• I understand that I have the right to request restrictions on the use and disclosure of my PHI: _____

Other Forms

• Advance directive form (e.g. living will, power of attorney)
• Consent for surgery or procedure form
• Consent for imaging or diagnostic tests form
• Consent for laboratory tests form
• Consent for medication form

Note: These forms are just examples and may need to be modified to comply with specific state or federal regulations, or to meet the needs of your healthcare provider.