Registration Form Please complete registration form below. If you have insurance, please bring insurance card to your appointment. Patient Information Today's Date:(required) Last Name:(required) First Name:(required) Marital Status: select single married divorced other Birth Date:(required) Age:(required) Sex: select male female Social Security: Address:(required) City, State, Zip Code:(required) Home Phone:(required) Cell Phone: Email(valid email required) Employement Status: select employed unemployed self-employed studen (required) Occupation: Employer: Employer Address: Employer Phone: How Did You Hear About Us? select insurance physician internet magazine friend family other (required) Reason For Today's Visit:(required) Medical History a. Illnesses: Select any that apply High Blood Pressure Heart Disease Stroke Migraines Diabetes Thyroid Disorder Asthma Emphysema Breast Disease Ulcers Hepatitis Kidney Disease Venereal Disease Arthritis Depression Other Illnesses Other Illnesses: b. Surgeries: c. Allergies (and reactions): Family Medical History Select any that apply High Blood Pressure Heart Disease Diabetes Anemia Thyroid Disorder Breast Cancer Colon Cancer Other Cancer Other Illnesses Other Cancer Other Illnesses New Field Patient Smoking Status Patient Smoking Frequency Patient Smoking Start Date Patient Smoking End Date How many alcohol drinks per week? 0 1 2 3 4 5 6 7 8 9 10 10+ Current Medications: Insurance Information (If applicable) Insurance Name: Primary Insured Name: Relationship to Primary Insured: select self spouse child other Primary Insured Birth Date: Insurance Id Number: Group Number: Plan Name: Visit co-payment: Emergency Contact Contact name:(required) Relationship: select spouse sister brother mother father aunt uncle child friend partner other (required) Contact address:(required) Contact City, State, Zip code:(required) Contact Home Phone:(required) Contact Cell Phone: The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Healthy Living Medical or insurance company to release any information required to process my claims. Type Full Name as Signature:(required) Authorization Date:(required) cforms contact form by delicious:days